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109 Caudle Meadows Drive Lot 725OPERATION PERMIT -Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 = _ Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Phil Strupe Builders, Inc. ._Address: 217 Riverwood Drive-- -CRY: rive=-CRY Lewi§ville _ .,atate2ip: ', NC- 27023• Property owner: Oak Valley Associates ;Address: 1598 Westbrook Plaza Dr City: Winston-Salem IStatetZip: NC 27103 j '.Phone #: (336) 723.0303 Property Location & Site Information _ Address/Road 4: Subdivision: _ Saddlebrook @ Oak Phase: Lot: 725 109 Caudle Meadows Drive _-'_Advance NC 27006 Directions structure SINGLE FAMILY _' " Hwy;158 turn right on Hwy 801, go to Mocks Church T :_ Rd on Right, to the stop sign, right on Beauchamp 4 -of Bedrooms Y4 v_ Rd. Development on the right. _. # of People: "Water supply: PUBLIC *IP Issued by 'System Classification/Description: TYPE III G. OTHER NON -COW. TRENCH SYSTEMS *CA issued by: 2tao-Nations, Robert Sap rolite System? OYes %No _ Design Flow ,,` *Dist GRAVITY -PARALLEL a Pump Required? 4 = 8 - 0 -_ ribution Type: (q. d -box) OYes QNo Soil Application Rate: 0.1 ? 5 *Pre Treatment: =- -- Drain field NdrificationField -a :.7 4 :S Sq. It. No. Drain Lines- 5 Total Trench Length: 4 4 0 ft• Trench Spacing: 9 Inches O.C. — • Feet O.C. Trench Width: 3 oInches Inches Aggregate Depth: inches *System Type: INFILTRATOR CUICK 4 STANDARD _ Installer: FrankTrensou Certification #: 2771 *EH S: 2140 - Nations, Robert Date: 1 0/ a 7„ / 2 0 1 6 Minimum Trench Depth: 3 Minimum Soil Cover, a 6 q Inches Inches AFF Maximum Trench Depth: 3 6 Inches ©'Appro� Maximum Soil Cover: as Inches CDP File Number 198007-1 Se Manufacturer. shoat - Inches STB: 760 " Gallons: t000 ❑ Yes ❑ No Date: 0 8/ a 1/ a 0 1 6 No *Filter Brand: POLYLOK Dual PL -122 With Pipe Adapter ❑ Yes ST Marker ❑ Yes 0 No ❑ Yes Reinforced Tank: ❑ Yes . _ ® No 1 Piece Tank `'❑ Yes — 0 -No ❑ Yes ❑ No Pt Manufacturer. PT: Gallons: Date: J,/ Riser Sealed ❑ Yes ❑ No RiserHeght: ❑YeS `." ❑ No (Min.6 in.) Reinforced Tank:.❑. YeS " __.._❑ No. - 1,Piece Tank:.. ❑ Yes_-_ -,.O -No . Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes - ❑ No Pump. Date: / . / Pum p Type: Installer: Dosing Volume: - Gal Certification #: Draw Down: *EHS: Date: Approvel Status ❑ Approved Disapproved .`; Inches 'Chain: Valves Accessible ❑ Yes ❑ No Flow Adjustment valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No PVC Unions ❑ Yes ❑ No Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes ❑ No Date: Approvel Status ❑ Approved Disapproved .`; ti CDP File Number 198007-.11 NEMA 4X Box or Equivalent ❑ Yes ❑ No Box 12 inches Above Grade ❑ Yes ❑ No Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No County ID Number: uipment Installer. Certification #: *EHS: Pump ManuallyOperable ❑ Yes ❑ No _ *Activation Method:- - Date: Approval Status AlarmAudrbte ❑Yes ❑ No 11Al Disapproved Alarm visible :Yes N0 2140 • Nations, Robert *Operation -Permit completed by: Authorized State Ageo Wil' Date of Issue: 1 0 / a 7 Owner/Applicant Signature: _ This. system has-been installed in compliance'with applicable NC General Statutes: Article 11, Chapter130A, Rules, for ::Sewage Treatment'and Disposal, -.1 5A NCAC=It3 A900 et. Seq., and all conditions of the Improvement Permit ands Construction AuthorMion..This property is served by a TYPE III G. sewage septic system. v" = - Rule X1961 requires -that a Type ==TSE III G. septic system meet the following criteria: MmimumSystem Review By The Local Health Department: WP - l .��Management Entity_ OWNER .:.Minimum System Inspection/Main ten an ce F req ue ncy B y C e dified Operator. Reporting Frequency By Certified Operator: NIA Rule A961requires that aType IV- and Vseptic system s.designed fora home/business owner must maintain avalid contract_.. _. Z�; _.wxh a publicmanagement*entitywih a certified operator or a private certified operator for the life of the septic system: .Rule .1961 requires that Type Vi septic systems designed fora home/business owner must maintain a valid contract with 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 fora system required to be maintained by a public or private management entity, unless the system ownerand certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and 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 Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** "` mmmmmmmmm mmmmmmm 0 CONSTRUCTION For office use only AUTHORIZATION *GDP Flle Number 198607, 1 �" �` Davie County Health Department County ID Number. q°I, dlili' Z l 8 210 Hospital Street Evaluated For NEW I'.o,��. P.O. Box 848 Township" i����i Vllli,i h MoCksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 1 1 / a 5 / .2 0 .2 0 Applicant: Phil Strupe Builders, Inc. Property Owner: Oak Valley Associates Address: 217 Riverwood Drive Address: 1598 Westbrook Plaza Dr CRY: Lewisville CRY: Winston-Salem Statell NC 27023 Stateil NC 27103 Phone*: (336) 945-9309. Phone # (336) 723-0303 Proaerty Location & Site Information Address/Road 9: Subdivision: Saddlebrook @ Oak Valley Phase: Lot: 725 109 Caudle Meadows Drive Advance NC 27006 Directions Structure: SINGLE FAMILY Hwy 158 turn right on Hwy 801, go to Mocks Church Rd on Right, to the stop sign, right on Beauchamp Rd. # of Bedrooms: 4 Development on the right. # of People: *Water Supply: PUBLIC /Site Classification: Provisionally Suitable SaproliteSystem? OYes ®No Design Flow: 4 8 0 Minimum Trench Depth: a 4\ Inches Minimum Soil Cover. 1 .1 Inches Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - a 7 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: `Distribution Type: GRAVITY- PARALLEL (eq.d-box) TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) SepticTenk: *Proposed System;, 25% REDUCTION Ndrification Field 1 7 4 5 Sq. ft. 1 '0. 0 0 Gallons 1 -Piece:. OYes ®No Pump Req ' . Q 0No. 0May BeRequired utred� Yes Pump Tank: Gallons No. Drain Lines 5 1 -Piece. -Oyes ONO Total Trench Length: 4, 3 :6 ft, GPM—vs— it. TDH Trench Spacing: _ g Olnches O.C. Dosing Volume: _ Gallons 0 Feet O.C. Trench Width: Inches _ 3 _ 1Feet Grease Trap: Gallons Aggregate Depth: inches t ONSF OTS-1OTS-Ill Tank Installer radio Lel RequirdlI Oil 0,111 OIV D... 4 of Q CDP File Number 198007-1 County ID Number. ❑ Open Pump System Sheet ReoairSvstem Reauired:OYes ONO ONO, but has Available Space I —" — Trench Spacing: 9Inches O! `Site Classification: Provisionally Suitable — • Feet O.C. Trench Width: Inches 3 gFeet Design Flow: 4 8 0 – Depth: Soil Application Rate:Aggregate 0 - a 7 5 inches Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE 11 A. CONY SYSTEM (SINGLE-FAMILYOR480 GPD OR LESS) Minimum Soil Cover .1 a Inches' Maximum Trench Depth: 3 6 *Proposed System: 250% REDUCTION Inches Maximum Soil Cover: _ a 4 Nitrification Field 1 7 4 5 Sq. ft. Inches No. Drain Lines 'Distribution Type: GRAVITY - PARALLEL (eq.d-box) 5 TotaiTrench Length: 4 3 6 Pump Required: OYes ®No OMay Be Required ft \ ProTreatment: ONSF OTS -1 OTS -11 , *Site Modifications No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department. *Permit Conditions The issuance ofthis 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 forwastewater System Construction shall bevalid for a person equal to the period of validity of the ImproVemem Permit, not to exceed five years, and maybe issued at the same time the Improvement Permit issued (NCGS 130A-338(1))} tt the Installation has not been completed during the period of validity 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 she is altered, the permit or Construction Authorization shall became Invalid and maybe suspended or revoked (.1937(g)). 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, maintenance, monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: Date:.. 'Issued By: 2140 -Nations, Robert . Date of Issue:, 1 1 / —.2-5 / e1 0 1 5 Authorized State Age Malfunction Log. OYes *Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 6avie County Heafth Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization. CDP File Number: 198007 -1 County File Number: Date: 1 1/ 2 5/.1 0 15 W W ` Qlnch _ f•__1 _. /'1 n�_J. � i 4 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 CDP File Number: 198007 -1 Mocksville NC 27028 County File Number: Date: 11/25 /2015 Click below to Import an Image from an external location: Drawing Type: Construction Authorization APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health PAI t� P.O. Box 848/210 Hospital Street Date: I Mocksville,NC 27028 Receivedb: (336)753-6780/Fax (336)753-1680 Application For: O Site Evaluation/hnprovement Permit 0 Authorization To Construct (ATC) PI Both Type of Application: ONew System DRepair to Existing System ❑Expansion/Modification of Existing System or Facility * * *IMPORTANT* ** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name.oe 13 v' jde, (.Fre- Contact Person %�%.1 � S�r v, A Address gij 121ufwvv r%, v e- Home Phone 33 6- g s 93 0 q City/State/ZIP ewrs v'//,e AAC 4'>0)-3 Business Phone Email /�Li•Y i�.-zz (2 t/c-�,oe. G w� Email: P:. De Name on Permit/Aif Different than Above Mailing Address ;LI'7 Rtyeeoya c/ pr City/State/Zip 4/r, TDate NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan OPlat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name Dai Vc,//sv ksocioer lj—t-JnW P"e Q2 Phone Number 33C-7ox3 Owner's Address f fISS 61kjV4" /, Ole ,P�e-CityfState/Zip W: s A-S�/e.� AK Property Address loci `u,,.dle /iewlows City Lot Size /.1.SS X a SJ Amb, Tax PIN# Subdivision Name(ifapplicable) S�l�//e1,.4 0 dwA KAeSection/Lot# Scc /� w� 1� Directions To Site: If the answer to any of the following questions is "Yes",supporting documey stick must be attached: Are there any existing wastewater systems on the site? Yes ✓ 0 Does the site contain jurisdictional wetlands? _Yes Vo Are there any easements or right-of-ways on the site? _Yes o Is the site subject to approval by another public agency? Yes -:;Fro Will wastewater other than domestic sewage be generated? Yes IF RESIDENCE FILL OUT THE BOX BELOW # People t'% # Bedrooms �' # Bathrooms 3 2 Garden Tub/Wbirlpool es 510 Basement: [?Yes V6' Basement Plumbing: o IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBusmess 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: VZo5riventional DAccepted 01nnovative CAlternative D Other Water Supply Type: �unty/City Water 0 New Well DExisting Well D Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes Tfves what tune? 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 charges, 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 identification and labeling of property lines and comers and locating and flagging or staking the house/facili location, proposed well location and the location of any other amenities. 44 Site Revisit Charge Property own s or owner's legal representative signature Date(s): ,/e _I eI_ e S� Client Notification Date: Date EHS: Sign given DYes ONo Revised 11106 Account # D Invoice # N APPLICATION FOR c.;ITE EVALUATIONAMP ROVEMENT PERMIT & ATC ]pavie County Health Department Environmental Health I eetion P.O. Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/ Fox (336)7:11-8786 Application For. 0 Site Evaluation/lmp'ovement Permit O Authorize( on To COnsimm(ATO) O Both num rre mnw rANNOrBEP20CEMED UIILESS ALL OF TAE REQUIRED Name to be Bill Billing Address Cityl itatelZIP _ Name on Pemdt/ATC ifDifferenl than r site plan must accompany this applicant] for 60 months with site plan, on, expiration Directions To If the anawerto any ofihe following questioaa is "yes", suppartivg docutuvwtio must be attacbed - Am there any existing wastrwrhr Systema on the site? OYts Does the site wnminjurisdidiosul wetlands? Ms o Are Were any easements or dlht-ofways on the site? OYes ENO Is the site subject to approval Sy another public agency? OYrs ONO Will wastewater other then domestic sewage be generated? OYte ONo , __........,...................rs.- nnv nvr AW Drn K)& .S SI Ulm ONO IF NON-RESII)ENCE FILL OL'T 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: #Seal ' Type systemrequested::Anvcntionsl OAccepted Olmovative OAlternadve nother Water Supply Type: C County/City Fater O New Well OFiasting Well 0 Community Well Do you anticipate additions or expo o -Ow Of the facility this system is intended to nerve? O Yes 1la<1 If yes, wbat type? _ This is to certify that the information lirovided on this application is nue soil correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hmcai'c. are subject to suspension or revecation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed lundt rstand that lam respansiblefor all charges incurred from this application. I hereby grant right of ecuy to the AuthmizedReprt arntative of the Davie County Health Deparmaent to conduct neves ons mune tom liars with applicable Iasis and rules on the above described property located in Davie County end oravmed inspection t "^ why Uaw i �ssol'j , � P. P sl�lp / ry°<1.r 1l,., M Site Revisit Charge fl E C E =APR6D Sign given uYes ONO Account # AOMM V M Revised 2106 Invoice # D12 —�' e Sn, 3 Sq. Ft..l raga 30,894 Sq., Ft. I " 1� �. 33,4266SSq. Ft. 9' °po• \96\ .S o Iq. Ft. es>� L�c�_(,ourse Drlve Fip tProw�C,Op Kassel n Kassel Igo ASA 327 Olp O 35,081 Sq. Ft. Ej ' 2 I 15 � I 30,(88 Sq. Ft. 270 16 I 33,469 Sq. Ft. I z64 I 17 )1 30,450 Sq. rt. I 60 18 j 30,(60 SqI. Ft. 1 255 I 19 I b 30,474 Sq. Ft I �1 St. Andrews Golf Villas Seotlon 9B, Phase II, Seatton 2 Plot Book 8, Page 21 SI"� egg° ^Q 34,956 Sq. R. I O 35,486 Sq. Ft. 145''' _ -�_ 142' —♦ t 1 22i' I 30,080 Sq. Ft. 1! 1I O 30,")80 Sq. Ft. i 70 2U I ,a.a I 30,37 Sq. Ft. S 1 I alnpI 22. I wid Oct 1626 pUb/;c R`\CSrl 9h f Of way. 162 0 30,078 Sq. Ft. O 30,078 Sq. Ft. O 30,040 Sq. Ft. 31,107 Sq. Ft. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003765 Tax PIN/EH #: 5871-25-2458.20 Billed To: Oak Valley Associates Limited Partne Subdivision Info: Sawgrass Lot # 20 Reference Name: Bo Davis Location/Address: Beauchamp Rd -27q061 Proposed Facility: Residence Property Size: see map Date Evaluated: 14 1� D fe Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit ✓ Cut FACTORS, 7 1. 2• 3 4 5. 6 7 Landscape position HORIZON IDEPTH ' Texture group C-L Consistence SS S Structure AAg CC - Mineralogy $ c HORIZON B DEPTH Texture groupG.. _. Consistence . } itf SV Structure Mineralogy HORIZON IH DEPTH - 2 -72- 2 ^ LZ 5 - C, Texture grouC_+ L+ e. Consistence Fr S P: S Structure C� Mineralogyc �L HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 'r ;.. RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S Its. LONG-TERM ACCEPTANCE RATE o. 3 o. b . 11 SITE CLASSIFICATION: EVALUATION BY: �1 Epl �AoC-QA" LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: REMARKS:? IJI s�1.On1(alU< ` (pT LEGEND +- LandscnoePosition R - Ridge .: S, -Shoulder,- L - Linear slope . , FS -Foot slope .: N - Nose slope <. CC -Concave slope ICV '- Convex slope T - Terrace FP - Flood plain H - Head slope'' Texture :. _ .. S -Sand LS -Loamy sand. SL --Sandy loam .L -Lo am ' ,' SI _ - Sil[ ' - _.. - SICL - Silty clay loam SIL- Siltyloam '; CL'- Clay loam'- SCL - Sandy clay loam . SC - Sandy clay: SIC = Silty clay C,= Clay CONSISTENCE VFR - Very friable FR - Friable Fl - Firm VFI Very firm EFI - Extremely firm .; SS - Slightly sticky 8 Y stickY S -Sticky VS Very Sticky" NP - Non plastic : , . SP =. Slightly plastic,;- P - Plastic .VP -Veryplastic ; . Structure - ' - .. _- ,. ._. - SC - Single grain ABK - Angular M =Massive CR -Crumb GR - Granular g blocky , . • SBK - Subangular blocky - PL -Platy -' PR - Prismatic -. - Mineralogy 1:1, 2:1, Mixed - 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 - gavdayna DCHD 05105 (Revised) Davie.County Healih Department, EnvironmentalHealth Section P.O. Box 848/210 Hospital Street Moeksville NC 27628 (336)751-8760/Fag (336)751-8786 - May 1, 2006 ^ Oak Valley Associates, Ltd. Partnership Attn: Bo Davis 3401 Healy Drive Winston-Salem, NC 27103 Re: SAWGRASS Proposed Subdivision / Lot # Caudle Tract / Beauchamp Road Tax PIN# 5871252458 Dear Client(s): As requested, a representative from this office visited the above site April 11, 12, 18, 2006 to perform site evaluations. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system: This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a wastewater system must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation if site plans or the intended use change. Improvement Permit System To Serve: r�L g fj��1pl� Wastewater Design Flow:_ System Type: ❑Conventional �ceptteed Dlnnovative ❑Alternative ❑Other System Location: , . D� L� 5,IOyp, ' �r- _Valid ears DNo Expiration Site Modifications/Permit Conditions: t l oCv a ps-i.p.letter 2/06