263 River Road Lot 8Davie Countv.'NC
7
Tax Parcel Renort
Wednesday. January 11. 2017
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage:
Deed Date:
Deed Book i Page:
Plat Book:
Plat Page:
Building Value:
WARNING:THIS IS INOTA SURVEY
Parcel Information
E806OA001001 Township: Shady Grove
5881151307 Municipality:
8302749 Census Tract: 37059-803
JOHNSON GLENN Voting Precinct: EAST SHADY GROVE
263 RIVER ROAD Planning Jurisdiction: Davie County
ADVANCE Zoning Class: DAVIE COUNTY R-20
NC Zoning Overlay:
27006 Voluntary Ag. District: No
LOT 8 GREENWOOD LAKES SEC I Fire Response District: ADVANCE
1.67 Elementa School Zone: SHADY GROVE
11/2013 Middle School Zone: WILLIAM ELLIS
009420718 Soil Types: GnB2,GnC2,GaD,RvA,ChA,WATER
3 Flood Zone:
53 Watershed Overlay: DAVIE COUNTY
Outbuilding & Extra
Freatures Value:
Total Market Value:
Land Value:
Total Assessed Value:
All data Is provided as Is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the
Davie County, implied warranties of merchantability or fitness for a particular use. All users of Davie Countys GIS webalte shall hold harmless the
County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all dalms or causes of action due to
NCor arising out of the use or Inability to use the GIS data provided by this websfte.
OPERATION PERMIT
Davie ColuInty Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028,
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Glenn Johnson
Address: 12140 Longbottom Rd
City: Trophill
State)Zil): NC 28685
Phone #: (336) 957-5615
Pro
Address/Road 4:
River Road
Advance NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
'Water Supply: NEWWELL
ri -or unice use univ
*CDPFfleNumber 124150-1
E8-060-AOO-10,
County ID Number,
Evaluated For, NEW
�&roperly Owner: Glenn Johnson
Address: 12140 Longbottorn Rd
City: Trophill
State/Zip: NC 28685
Phone #: (336) 957-5615
oe[!y Location & Site Information
Subdivision: Greenwood Lakes Phase: 5 Lot: 8
Directions
Hwy 158, turn right on Hwy 801, then left on
Underpass, Left on River Rd, Lot on Left beside 247
River Rd.
1113 Issued by.
'System Class ification/Desc ription:
TYPE 11 A. COW SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by:
Saprolite System? OYes ONo
Design Flow:
4
8
0
'Distribution Type: GRAVITY -SERIAL Pump Required?
OYes eNo
Soil Application Rate: 0
4
'Pre -Treatment:
Drain field
kn Ica
Nitrification Field
(""'No.
1 2
0 0
Sq. ft. *Systern Type: INFILTRATOR OUICK 4 STANDARD
:D
Li es
Dratin Lines
3
Installer: Fank Transou
Total Trench Length:
3
0 8
It.
Certification #:
Trench Spacing:
0 QInches
0
O.C.
Feet O.C. *EHS: 2140 - Nations, Robert
Trench Width:
Olnches
Veet
0 3 / 1 2 2 0 1 4
Date:
Aggregate Depth:
inches
Minimum Trench Depth:
3
0
Inches
Minimum Soil Cover
1
8
Inches
"Approval -status
Maximun
Maximum Trench Depth:'3
6
IF Ap piroV d Ditapproved
0, )d
Inches
m Soil Cover:
Maximur,
2
4
Inches
I E8-060-AOD-10
CDP File Number 124150 - I County ID Number:
Manufacturer shoal
STB: 760
Gallons: l000
Date:
1�2/
03
/2013
*FilterBrand:
1
POLYLOK PL -122 With Pipe Adapter
ST Marker
Yes
[i]
N 0
Reinforced Tank:
El
Yes
ffl
N o
No
1 Piece Tank:
El Yes
0
� �11ece Tank:
0 Yes
R
No
a
Let.
Long:
Installer fank Transou
Certificafion;g:
*EHS: 2140 - Natkzs. Robert
Date: 0 3 / 1 2 / .2 0 1 5
Approval Status
�ffl ApprovedEl Disappiroved"
Pump Tank
Manufacturer Installer.
PT: Certification
Gallons: THS:
Date:
RiserSealed
0 �Yes
0
No
RiserHeight:
0 �Yes
El
No (Min. 6 in.)
nforced Tank:
El Yes
El
No
1 Piece Tank:
El Yes
0
No
Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated 0 Yes 0 No
�pproved fittings Yes El N o
Date:
Date:
Approval Status
Approved El Disapproved
PumpType: Installer
Dosing Volume: Gal Certification ig:
Draw Down: Inches *EH S:
*Chain: i
Date:
Valves Accessible
El Yes
El
No
Flow Adjustment Valve
El Yes
El
No
Check -valve
0 Yes
0
No
Approval Status
PVC Unions
El Yes
0
No
Appro,ved'O, Disapproved
Vent Hole
r-1 Ves
M
Mn
CDP I File Ndmber 124150 - I County ID Number: E8-060-AOO-10
N EMA 4X Box or Equivalent E] Yes
Box 12 inches Above Grade 0 Yes
Box Adj. To Pump Tank El Yes
Conduit Sealed El Yes
Pump Manually Operable El Yes
*Activation Method:
Alarm Audible El Yes
Alarm Visible El Yes
*Operation Permit completed by;
Authorized State Agent:
Owner/Applicant Signature:
IMICUILIFIG =Quipme"t
0 No Installer
0 No Certification
E3 No
E3 No *EHS:
Date:
El N o Appraval,,Status.
01�,,46rovedn bisapproved,
D No
2140 - Nations. Robert
Date of Issue: 0 3 / 1 2 / 2 0 1 5
This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq., and all conditions of the Improvement Pe ' rmit and
Construction Authorization. This , property is served bya T)(PE it x sewage septic system.
Rule .1961 requires that a Type TYPE11A. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: NIA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCertified Operator.
NIA
Reporting Frequency By Certified Operator: NIA
Rule .1961 requires that a Type IV and V septic systems designed for a hom e/business owner must maintaina valid contract
with a public management entitywkh a certified operatoror a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract wdh a
public management entity with a certified operator for the life of the septic system.
Rule, 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the ownerand systems operator, provisions that the contract shall be in effect.for as long as the
system is in use, and other requirements for the,continued proper performance of the system. It shall also be a,condition of
the I Operation Permit that subsequent owners of the systems execute such a contract.
(kHand Drawing 0importDrawing
**Site Plan/Drawing attached,.**
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawin2 Dravving Type: Operation Permit
CDPFileNumber: 124150-1
County File Number: E8 -060 -AGO -10
Date:
0 Inch
Scale: OBlock
ON/A
. ........ .
.........
.
Alki
. . ...........
........
. .................... . .
. ...... . ...... .
:j
--------- -
------------
.
...... . . . ....
.......... ... . .... ......
... . ...... .
- --- - --
-------
A
............
. - - - ----- -
.....
.... . . ............
. ... .......
. ....... ...
-CONSTRUC'nON For Office Use Only
AUTHORIZATION PAM ICDPFileNumber 124150-1
Davie County Health Depart County ID Number: E8 -060-A00_10
210 Hospital Street Evaluated For: NEW
P.O. Box 848
�Izownship:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 1 1 / 1 9 2 0 1 8
Applicant: Glenn Johnson Property Owner: Glenn Johnson
Address: 12140 Longbottorn Rd . FAddress: 12140 Longbottom Rd
Gay: Trophill City: Trophill
St /Zip.
State/Zip: NC 28685 State/Zip: NC 28685
Phone#: (336) 957-5615
AddressfRoad 9: Subdiv
River Road
Advance NC 27028
Structure: SINGLE FAMILY
9 of Bedrooms: 4
4 of People:
"Water Supply: NEW WELL
on gtion
Greenwood Lakes ) Phase: 5 Lot: 8
Directions
Hwy 158, turn right on Hwy 801, then left on Underpass,
Left on River Rd, Lot on Left beside 247 River Rd.
/Site Classification: PS Minimum Trench Depth: 2 4 Inches
Saprolite System? OYes ONo Minimum Soil Cover Inches
Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 4 Maximum Soil Cover: Inches
*Systern Classification/Description: *Distribution Type: GRAVITY - SERIAL
TYPE 11 A. COW SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) C� fiiTnntee
*Proposed System: 25% REDUCTION
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
Sq. ft.
3 0 0 ft.
1 0 0 0 Gallons
I -Piece: OYes ONo
PumpRequired: OYes ONo OMayBeRequired
Pump Tank: Gallons
1 -Piece: OYes ONo
GPM—vs— ft. TDH
_8Inches O.C. Dosing Volume: Gallons
Feet O.C.
__8Inches
Feet Grease Trap: Gallons
inches Pre -Treatment: ONSF OTS -1 OTS -11
Septic Tank Installer Grade Level Required: 01011 0111 01V
Page I of 3
V E8-060-AOO- 10
CDP'File Number 124150 - 1 County ID Number:
0 Open Pump System Sheet
uired:OYes GNo ONo, but has Available S
,-'Repair System
Trench Spacing: Inches 0.
*Site Classification: — —8Feet O.C.
**** 15A NCAC 18ftwII1945 8 Inches
Design Flow: Feet
Soil Application Rate: Aggregate Depth: inches
*System Class ificat ion/Desc ri Minimum Trench Depth: riches
Re*pair Area Exe mpt— I
Inches
*Proposed System: Maximum Trench Depth: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq. ft.
No. Drain Lines 'Distribution Type:
Total Trench Length: ft. Pump Required: 0Yes ONo OMay Be Required
Pre -Treatment: ONSF OTS -1 OTS -11
^Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without a6proval of Health Department.
*Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit not
to exceed five years, and maybe Issued at the sane time the ImprovementPermit Issued (NCGS 13OA-336(b)� If the Installation has not been
completed during the period at wildity of the Construction Permit. the Information submitted In the application for a permit or Construction
Authorization Is found to have been Incorrect falsified or changed. or the site Is altered. the permit or Construction Authorization shall become
invalid, and maybe suspended or revoked(.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, riales, and permit conditions regarding system location, Installation. operation, maintenarice� monitoring. reporting and repair
(1938(b)).
Applicantfl-egal Reps. Signature Required? OYes ONo
Applicant/Legal Reps. Signature- Date: / /
21ssued By- 2244 - Daywall, Andrew
Authorized State Agent:
Date of Issue: 1 1 / 1 9 / 2 0 1 3
Malfunction Log OYes
01 -land Drawing Olmport Drawing Total Time:(H 1-1111-1)
**Site Plan/Drawing attached.**
Page 2 of 3 0 1 1 Hours 0 0 1.11nutes
S-8 - CA'S issued - now
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 124150 - I
210 Hospital Street County File Number: E8-060-AOO-10
P.O. Box 848
Mocksville NC 27028 nnfa. I I / 1 0 / I A I Q
t ' �/74 W
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Environmental Health
-FMP3� P.O. Box 848/210 Hospital Street RECEIVED
DOW. - 6.4 '&-1 1, Mocksville, NC 27028
W, (336)753-6780/ Fax (336)753-1680 Date:
V,k5� � qevyya �tv�,�Iun
Application For: 0 Site Evaluation/Improvement Permit 0 Authorization To Construct (ATC) 0 Both
Type of Application: DNewSystem 0 Repair to Existing System DExpansion/Modification of Existing System or Facility
***IMPORTA1VT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name 6_11eol,% J-_-At)5,7^ ContactPerson &enl Zkn.5,
Address HornePhone
City/State/ZIP MCX*ff(-1 e_4�2A;1� 17,L:, '28 600 5- Business Phone /,(,,:-_5 (C)
Email 6, 61:5,y� A,.n, r,, , Ernail:6- 25. Wel
Name on Permit/ATC if Different than Above 6towrium &95QqaWQ -com
Address
PROPERTY INFORMATION *Date House/Facilitv Comers
NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan OPlat(to scale)
�Permit i� valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name 61-eit Phone Number 336 -?X7-_6&
Owner's Address 1.a1q,0 4.,,Pf City/State/Zip
Property Address_/,,ee,0�1V Alaze,3 41,eZ'k Ci 4" !1 e- e'
Lot Size Tax PIN#
Subdivi*sion Name(if applicable) 6 4�14;64krh�j Section/Lot# 4 ht f,-- 5: Zo
Directions To Site: /" 4. -1al. 2. 7
If the answer to any of the following questions is "Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site?
—Yes -go
Does the site contain jurisdictional wetlands?
--Yes
Are there any easements or right-of-ways on the site?
e -No
Is the site., s�bject to approval by another public agency?
—Yes
Yes /No
Will wastewater other than domestic sewap-e be-atrimted?
Yes ef�o
IF RESIDENCE FILL OUT THE/99�CBELQW
# People a # Bedroo Iq A Z # Bathrooms -'2,5 Garden Tub/Whirlpool Rfes DNo
Basement: Wfes ONo Baserneft Plumlimg: [��es DNo
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: 21(�onventional DAccepted 01nnovative DAltemative 00ther
Water Supply Type: O'County/City Water 0 New Well 0 Existing Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? 0 -Yes R_f�o'
If yes, what type?
------- -- --------- - ------
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use
changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that I am responsible for the proper iaentification and labeling of property lines and comers and
locat?i d fi or staking the house/facility location, proposed well location and the location of any other amenities.
,yn ��gi_
Site Revisit Charge
Property o,4&r's or owner's legal representative signature
Date(s):
Client Notification Date—:
Date EHS:
Sign given DYes ONo Account # IV415-0
Revised 11/06 Invoice #
T
Uot
Applicant:
Address:
City:
StatefZip:
Phone;ff:
Address/Road 9:
River Rd
Advance
Structure:
9 of Bedrooms:
4 of People:
'Water Supply:
C.ONSTRUCTION
AUTHORIZA110N
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
/I For Office Use Onl
*CDPFileNumber 81337-1
County ID Number: E8D60AO010
Evaluated For: NEW
\, Township:
Phone: 336-753-6780 Fax: 336-753-1680 a 7 / .1 0 1 8
Andrew Hansen Property Owner: Sylvia Hudson
167 Warwicke Place rAddress: 273 River Rd
City
Advance City: Advance
NC 27006 StatefZip: NC 27006
(336) 998-2883 ) ( Phone #:
Subdivisig4f Greenwood Lakes _'N Phase: 5 Lot: 8
NC 27006 Directions
SINGLE FAMILY 140 exit Hwy 801 going south., turn left on Underpsss Rd.
then left on River Rd. Lot on left beside 273
3
PUBLIC
/Site Classification:
Minimum Trench Depth: 2 4 Inches
Saprolite System? OYes QNo
Minimum Soil Cover Inches
Design Flow: 3 6 0
Maximum Trench Depth: 3 6 Inches
Soil Application Rate* 4
Maximum Soil Cover: Inches
*System Classification/Description:
*Distribution Type:
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0
Gallons
*Proposed System: 25% REDUCTION
I -Piece: ()Yes ONo
Pump Required: OYes ONo 0 May Be Required
Nitrification Field
Sq. ft. PumpTank: Gallons
No. Drain Lines
I -Piece: OYes ONo
Total Trench Length: .2 a 5
GPM—vs— ft. TDH
Trench Spacing: 9 0 0
Inches O.C.
8Feet O.C. Dosing Volume: Gallons
Trench Width: 3 6
Inches
8Feet
—
Grease Trap: Gallons
Aggregate Depth: inches
Pre -Treatment: QNSIF OTS -1 OTS -11
Septic Tank Installer Grade Level Required: 01011 0111 01V
Pagel of3
CD13 File N 6m 4er '81337 - 1 County ID Number: E8060A0010
Open Pump System Sheet
Repair System Required: OYes ONO ONO, but has Available Space
epair System Trench Spacing: Inches 0.
9 0 0 06
'Site Classification: Ps �3- Feet O.C.
Trench Width: 0 Inches
rDesign Flow: 3 65 e t
3 6 0 J 0 0 Feet
Soil Application Rate: 4 Aggregate Depth: inches
*System Class ificat ion/Desc ription: Minimum Trench Depth: 2 4 Inches
TYPE 11 A. CONV SYSTEM (SINGLE-FAAIILY OR 480 GPD OR LESS) Minimum Soil Cover
Inches
'Proposed System: 25% REDUCTION
Nitrification Field Sq. ft.
No. Drain Lines
Total Trench Length: 2 .1 5 ft.
Maximum Trench Depth: 3 6 Inches
Maximum Soil Cover:
Inches
'Distribution Type: GRAVITY -SERIAL
PumpRequired: 0y0s (DNo OMayBeRequired
Pre -Treatment: ONSF OTS -1 OTS -11
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit bythe Health Department in no way guarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater System Construction shall be valid for a person equal to the period dvalldity of the Improvement Permit not
to exceed five yeam. and maybe Issued at the same time the ImprovementPermit issued (NCGS 13OA-336(b)� If the Installation has not been
completed during the period of validity of the Consruction Permit, the Information submitted In the application for a permit or Construction
Authorization Is found to have been Incorrect, falsified or changed. or the site Is altered, the permit or Construction Authorization shall become
Invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling Vie system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, Installation, operatiom maintenance6 monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? OYes ONO
Applicant/Legal Reps. Signature, Date:
*Issued By*
2244 - Daywalt,
Authorized State Agent:
Date of Issue: 0 2 / 0 7 / 2 0 1 3
Malfunction Log OYes
GHand dfawirig 0import Drawing Total Time:(1-11-1-111.1)
**Site Plan/Drawing attached.** Hours 0 IJ inutes
Page 2 of 3
'..IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
(" _F
*CDP File Number 81337 - I
County ID Number: E806OA0010
Evaluated For: NEW
�T!ownship:
Phone: 336-753-6780 Fax: 336-753-1680 PERUIT VALID UNTIL: 2/1/2018
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit.
Applicant: Andrew Hansen
Address: 167 Warwicke Place
City: Advance
State/ZiP: NC 27006
Phone 9: (336) 998-2883
'Address/Road 9:
River Rd
Advance NC 27006
Structure: SINGLE FAMILY
4 of Bedrooms: 3
"� of People:
*Water Supply: PUBLIC
n:
Saprolite System? OYes ()No
Design Flow: 3 6 0
11
Property Owner: Sylvia Hudson
Address: 273 River Rd
City: Advance
State/Zip: NC
Phone 9:
I-
27006
Subdivision: Greenwood Lakes Phase: 5 Lot: 8
Soil Application Rate: 4
*Systern Classification/Description:
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Directions
1-40 exit Hwy 801 going south., turn left on
Underpsss Rd. then left on River Rd. Lot on left
beside 273
e
Minimum Trench Depth: 0 2 4 Inches
Maximum Trench Depth: 3 6 Inches
Septic Tank: 1 0 0 0 Gallons
1 -Piece: OYes (?No
Pump Required: OYes 0 No C) May Be Required
Pump Tank: Gallons
1 -Piece: OYes ONo
Repair System Required: 0 Yes ONO ONO, but has Available Space
.Site Classification: PS
Soil Application Rate: 4
'System Class ificatio n/Desc riptio n:
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPID OR
LESS)
*Proposed System: 25% REDUCTION
Minimum Trench Depth: a 4 Inches
Maximum Trench Depth: 3 6 Inches
Pump Required: OYes (3iNo OMaybeRequired
Pagel of3
CDP, File Numb.er 81337 -
County ID Number: E806OA0010
*Site Modifications El Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits. The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
The knprovementP*rmitshal be valid for 5yearsfrom date of Issue With a site plan (means a drawing not necessarily drawn to
Site Plan scale that shows the existing and proposed property lines with dimensions. the location of thefacility and appurtenances, the
(D site for the proposed Wastewater system, and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valldwithout expiration With plat (means a property surveyed prepared by a registered land
0 :Urveyor, drawn to a scale atone Inch equals no morethan 60 feet that includes: the specific location of the proposed facility
nd appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters. Plat
also means, for subdivision lots approved by the local planning authority and recorded with the county register of deeds, a copy
of the recorded subdivisions platthat is accompanied by a site plan that Is drawn to scale).
The Department and Local Health Department may Impose conditions on the Issuance and may revoke the permits for failure of
the system to satisfy the conditions, the rules, or this article, This permit Is subjectto revocation if the site plan, plat, or Intended
use changes (NCGS 13OA-335(Q). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenancft monitoring,
reporting, and repair (.1 938(b)�
Applicant/Legal Reps. Signature Required? OYes GM0
Applicant/Legal Reps. Signature:
Date: / /
*Issued By, 2244-Daywall.Andrew Date of Issue: I / 1 / 2 0 1 3
Authorized State Agent: OValid without Expiration?
0 Create CA?
01 -land Drawing Olrnport Drawing
**Site Plan/Drawing attached.** Total Time:(1-11-111M)
1 Hours 0 1.1 inutes
Page 2 of 3
Activdv Code:
IMPROVEMENT PERMIT . 81337-1
Davie County Health Department CDP File Number.
210 Hospital Street County File Number: E806OA0010
P.O. Box 848
A.PPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
pjzc
Davie County Environmental Health I
P.O. Box 848/210 Hospital Street
"Ov 0 2012
Mocksville, NC 27028
(336)753-67801 Fax (336)753-1680
Application For: U/S/ite Evaluation/Improvement Permit 0 Authorization To Construct (ATC) -
Type ofApplication: ONewSystem ORepairto Existing System DExpansion/Modification of Existing System or Pacility
***IWORTANT*** THIS APPLICATION CAMVOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPTJCANT INFORMATION
Name 91 VA C- (1) IJA Contact Person 4111ja -
Address Home Phone
City/State/kfP fia(yllfueelx AJ(-, Z26% Business Phone -33(0 XI -1-0311
Email
Name on Permit/ATC if Different than Above
Mailing Address
PROPEKI'Y INFUKKA11UN
1-0
6.1
*Date House/Facility Comers
NOTE:. A survey. plat or site plan must accompany this application. Included: 0 Site Plan OPlat(to scale)
(Permit is vAi-' - 50 months wi saitp plan, no expiration with complete plat.)
Owner's Name" - Adkl) Phone Number
Owner's Address ��-13 �12;vkir 1201 City/S te/Zip
Property Address slve-,te (Q- � city lu
Lot Size Tax PIN# &OA 0010
Subdivision Name(if applicable)__& akes Section/Lot#
Directions To Site:
If the answer to any of the following questions is,"Yes",supporti�igdocumentation must be attached:
Are there any existing wastewater systems on the site? "Y e s — No
Does the site contain jurisdictional wetlands? —Yes —No
Are there any easements or right-of-ways on the site? —Yes No
Is the site subject to approval by another public agency? Yes No
Will wastewater other than domestic sewage be generated? Yes No
IF RESIDENCE PIT J, 01 TT THF, BOX BELOW
# People f- 4 Bedrooms �� # Bathrooms -57 ;7"2- Garden Tub/Whirlpool OYes. 04o
Basement: �fyes ONo Basement Plumbing: NYes E]No
IF NON -RESIDENCE FIT.T. OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) _(Attach documentation of similar facility water consumption)
FOODSERVICE, ONLY: #Seats
Type system requested: U065nventional OAccepted 01nnovative OAltemative 00ther
Water Supply Type: LjXunty/City Water 0 New Well El Existing Well 0 Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 0 No
If yes, what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s) or ATC(s) issued hereafter are subject to suspension or rev ocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I d
0 aed that I am respons Uble for the proper identification and labeling of property lines and comers and locating and flagging
ni
an
ta
st
tthe ouse/fhcijit�( lo ati n, pro osed well. location and the location of any.other amenities.
"g &,/,u \ J � C-7--� - Site R6visit Charge
Property owner's or owner's legal representative signature
Date(s):
/ Client Notification Date:
ate EHS:
-4ZA4J
Sign given DYes ONo Account #
Revised 11/06 Invoice #
, A
ON
APPLICANT INFORMATION
Account #: 990005964
Billed To: Andrew Hansen
Reference Name:
Proposed Facility: Residential
Water Supply: On -Site Well
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: E806AOOIO
Subdivision Info: Greenwood Lakes 5 Lot # 8
Location/Address: River Road -27006
Property Size: See Map Date Evaluated: z[
q1jz___
Community Public
Evaluation By: Auger Boring &_ . - pit
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position E S V�s
Slope % " IL �Oln
HORIZON I DEPTH _14(. 6 -4� n
Texture group L '0
- -L=
Consistence
Structure
Mineralogy VA
HORIZON II DEPTH
Texture group 41 UNd
Consistence 111L
Structure Mt'lAi
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: T5
LONG-TERM ACCEPTANCE RATE:
543XVIRM
EVALUATION BY &14hVLJ J�96�9�
OTHER(S) PRESENT: Apvu
LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope
Texture
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moht
VFR - Very friable FR - Friable F1 - Firm VFI - Very firm EFI - Extremely firm
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
1: 1, 2: 1, Mixed
Nato
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma. 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised)
mom
MEIVEMEME MIREMOM ff'F-)kMMMMMM EMMAMME MEMEMSEM NNE MESON
MEMEME mommoll offluass ENRUEN EMMONS MENNEN MEMENS
MEMEME ON MOEN MENEM
NONE
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