122 Caudle Meadows Drive Lot 708Applicant: The Veritas Group Inc Property Owner. The Veritas Group Inc
a.
Address: PO Box 528
OPERATION PERMIT
-
Davie County Health Department
27285 State/Zip.' NC 27285
210 Hospital Street
Phone #: (336) 404-1522
P.O. Box 848
Location & Site Information
Mocksville NO 27028
SubdWsion: Saddlebrook @ Sawgrass Phase: Lot: 708
Phone: 336-753-6780 Fax: 336.753-1680
Applicant: The Veritas Group Inc Property Owner. The Veritas Group Inc
Address: PO Box 528
Address: PO Box 528
City: Kemersviile
Cay: Kemersville
State/Zip: NC
27285 State/Zip.' NC 27285
Phone #: (336) 404-1522
Phone #: (336) 404-1522
Provertv
Location & Site Information
Address/Road #:
SubdWsion: Saddlebrook @ Sawgrass Phase: Lot: 708
Caudle Meadows Drive
Advance NO 27006
Directions
Structure: SINGLE FAMILY
Hwy 158 right on hwy 801, right on Mocks Church
Rd. right on Beauchamp Rd. road on right
# of Bedrooms: 4
# of People:
y: PUBLIC
j System Classification/Description:
.
TYPE II A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
: 2140 -Nations, Robert
rDesignFlow:
Saproiite System? ®Yes QNo
4 8 0
OistributionType: GRAVITY -SERIAL Pump Required?
QYes QNo
on Rate: 0 .2 7
5 'Pre Treatment:
Drain field
Nlrification Field 1
7 4 5 Sq. It. 'System Type: INFILTRATOR QUICK 4 STANDARD
No. Drain Lines 4
Installer: Frank Transou
Total Trench Length: 4 4
2 ft. Certification #: 2771
Trench Spacing: -9
Inches O.C.
• Feet O.C. 'EH S: 2140 - Nat ons. Robert
Trench Width:Inches
—.
3 BFeet 0, 8 / 1 1/ x 0 1 5
i Date: _
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. 1 4 _
Inches Approval Status
MaximumTrenchDepth, 3 6
'� Approved❑ Dlsapproved�
Inches
Maximum Soil Cover: 2 4
Inches
CDP File Number 191385 -1
Manufacturer. Shoaf
STB:
760
Gallons:
1000
Manufacturer.
Date:
0 5/
a 4/
a 0 1 5
*Filter Brand:
POLYLOKPL-122 With Pipe Adapter
ST Marker.
❑ Yes
®
No
nforced Tank:
❑ Yes
0
No
1 Piece Tank:
❑ Yes
R
No
Date: /
/
County ID Number: -
Lat.
Long:
Installer: FrankTransou
Certification #: 2771
*EHS: 2140 - Nations, Robert
Date: 0 8/ 1 1 / 2 0 1 5
'Approval Stl. atus
App'roved ❑ El—
Pump
Pump Tank
Manufacturer.
Installer.
PT:
Certification #:
Gallons:
*EHS:
Date: /
/
Date:
RiserSeeled ❑ Yes
❑
No
Riser Height: ❑ Yes
❑
No
(Min.6
in.)
Approval Status
Reinforced rank: ❑ Yes
❑
No
❑ Approved ❑ Disapproved
1 Piece Tank: ❑Yes
❑
No .
..
Supply Line
Pipe Size: inch
diameter
Installer.
Pipe Length:
feet
Certification #:
*Schedule:
*EHS:
Pressure Rated ❑ Yes
❑
NO
Date:
Approved fittings ❑Yes
❑
NO
Appioval Status
Approved ❑
,Disapproved
Pump
Requirement
Pump Type:
Installer:
Dosing Volume:
—
Gal Certification#:
Draw Down:
Inches
*EHS:
*Chain:
Date:
Valves Accessible ❑ Yes
❑
No
Flow Adjustment Valve ❑ Yes
❑
No
Check -valve ❑ Yes
❑
NO
i. ,Approval; Status s
PVC Unions ❑ Yes
❑
No
E]
'A Disapproved
Vent Hole ❑ Yes
❑
NO
Anti -siphon Hole ❑ Yes
0
No
CDP File N umber' d 91385 -1
NEMA 4X Box or Equivalent ❑ Yes
Box 12 inches Above Grade ❑ Yes
Box Adj.To Pump Tank ❑ Yes
Conduit Sealed ❑ Yes
Pump Manually Operable ❑ Yes
*Activation Method:
Electric
❑ No
❑ No
❑ No
❑ No
❑ No
Alarm Audible ❑ Yes ❑ No
`. Alarm Visible ❑ Yes ❑ No
2140 - Nations, Robert
*Operation Permit completed by:
County ID Number:
Installer.
Certification #:
*EHS:
Date: / /
Approval Status
❑°"Approved ❑ Disapproved=
Authorized State Agent: 1 _--"'O",4Date of Issue: 0 8/ 1 1/ 2 0 1 5
Owner/Applicant Signature:
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 at. Seq., and all conditions of the Improvement Permit and
Construction Authorization. This property is served bye TYPE a A. sewage septic system.
- `Rule .1961 requires that a Type TYPE 11 A septic system meet the following criteria: -
Minimum System Review ByThe Local Health Department: N/A
,. __Management Entity: OWNER
Minimum System Inspection)Maintenance Frequency By Certified Operator:
WA
Reporting Frequency By Certified Operator: IVA
Rule .1961 requires that a Type IV and V septic systems designed fora hometbusiness owner must maintain a valid contract
with a public management entity with 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) (a) 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 bye public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements form aintenance 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. ft shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
(F)Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.** '''`
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
CDP File Number: 191385-1
County File Number:
27028 Date:
W W `
O Inch
Scale: OBlock
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MEN
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me
MENNNOMMENEEMMEN
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MENEM
-CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. BOX 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: The Veritas Group Inc
Address: PO Box 528
City: Kernersvilie
State/Zip: NC
Phone #: (336) 404-,1522
Address/Road M
Caudle Meadows Drive
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
*Water Supply: PUBLIC
For Office Use Onlv
'CDP Flle Number 1913857"':1 °'' i,ghl"I
County ID Number. ,
Evaluated For I NEW
0 3/ 1 7/ a 0 a 0
Owner: The Veritas Group Inc
Address: PO Box 528
City: Kemersville
27285 State2ip: NC 27285
Phone #: (336) 404-1522
Subdi4ision: Saddlebrook @ Sawgrass Phase:
Classification: Provisionally Suitable
Saprolite System? Oyes ®No
Design Flow: 4 8 0
Directions \
Hwy 158 right on hwy 801, right on Mocks Church Rd.
right on Beauchamp Rd. road on right
I
1
Minimum Trench Depth: a 4 Inches
Minimum Soil Cover. 1 a
Inches
Maximum Trench Depth: 3 6
Inches
Soil Application Rate: 0 2 7 5 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY -SERIAL
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 _ Gallons
`Proposed System: 25% REDUCTION 1 -Piece: OYes OQ No
Pump Required: 'OYes®No OMay Be Required
Nitrification Field 1 7 4 5 Sq. ft. Pump Tank: Gallons
No. Drain Lines 4 1 -Piece; OYes ONo
Total Trench Length: 4 3 6 ft, GPM—vs— ft. TDH
Trench Spacing: Inches O.C.
9 . ®Feet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
— 3 BFeet Grease Trap: Gallons
Aggregate Depth: inches PreTreatment: ONSF OTS -1 OTS -11
Septic Tank lnstallerGrade Level Required: 01 OII 0111 OIV
Dena 4 ^f'A
CDP File Number 191385 - 1 County ID Number..
❑ Open Pump System Sheet
ONO ONO, but has Available
'"��" �' ""'
*Site
Trench Spacing:
Inches O:
9 Feet O.C.
Classification:
,Provisionally Suitable
—
Trench Width:
Q Inches
3 gFeet
Design Flow:
4 8 0
—
Depth:
Soil Application Rate:Aggregate
0 - a 7 5
inches
Minimum Trench Depth:
a 4
Inches
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD_OR LESS) Minimum Soil Cover
1 i2
Inches
*Proposed
Maximum Trench Depth:
3 6
Inches
System:
25% REDUCTION
Maximum Soil Cover.
a 4
Nitrification Field
1 7 4 5Sq. ft.
Inches
No. Drain Lines
*Distribution Type:
GRAVITY -SERIAL
4
Total Trench Length:
4 '3 '6'
Pump Required: Oyes
®No
OMay Be Required
it.
\
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 wayguarantees the Issuance of other per fts. 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 atthe sanetims the improvement Penult issued (NCGS 130A336(b)} If the installation has not been
completed during the period of validity ofthe Construction Permit, the information submitted In the application for a permit or Construction
Authorization Is found to have been Incorrec%falsified or changed, or the site 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 forassurintg compliance
with the laws, rules, and permit conditions regarding system location, Installation, opera0on, maintenance, monitoring, reporting and repair
(1939(b)). _
Applicent/Legal Reps. Signature Required? OYes ONO
ApplicenVLegal Reps. Signature: Date:, / /
*Issued By: 2140 -Nations, Robert Date of Issue: 0 3/ 1 7/ 2 0 1 5
Authorized State Agent Malfunction Log OYes I,+'
®Hand Drawing OlmportDrawing
**Site Plan/Drawing attached.**
Page 2 of 3
° CONSTRUCTION AUTHORIZATION
Davie: County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type:.Construction Authorization
CDP File Number: 191385 -1
County File Number:
Date: 03/13/2015
W W
Q Inch
Scale:. 0131ock ft.
APPLICATION FOR SITE EVALUATION/IMPROVEWNT PERNIIT & ATC
RECEIVED Davie County Environmental Health
P.O. Box 848/210 Hospital Street PA
Mocksville, NC 27028 Date: /�
(336)753-6780/ Fax753-1680
Application For: D Site Evaluation/improvement Permit Authorization To Construct (ATC) D Both
Type of Application: DNew System DRepair to Existing System DExpansion/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 —17ig- UeC�6,5 Gtoo,y . ?Ju=
Address V-0. t5oyc
City/State/ZIP Crr�e15 ✓! / !�-p�7a�
Email white✓P,E L S . ed-' —
Name on Permit/ATC if Different than Above ^—
Mailing Address
wMm»a swei►;asi:+wra4C91►1
Date
Home Phone
isinessPhone 33G-yar/tS'a�
NOTE: A survey plat or site plan must accompany this application. Included: D Site Plan DPlat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name T7 --e en &-s lo'roo Phone Number 33
Owner's Address d•134x S�'p2 «ners+�f t�,e City/State/Zip /vim �'
Property Address P_(►�u C It ML� City
Lot Size Tax PIN# r7
Subdivision Name(if applicable) IL Ik!!< Section/Lot# /(i
Directions To Site: 5so/ So%.A� •-,e U.16« /5).,!.1
Specify Problem Occurring:
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms .2 •S Garden Tub/Whirlpoo J4Yes DNo
Basement: OYes Po Basement Plumbing: ❑Yes 0&0
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: Oonventional DAccepted ❑Innovative DAltemative ❑Other
Water Supply Type: Vounty/City Water D New Well DExisting Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ko
If yes, what type?
This is to certify that the information provided on this application is true and correct to the best of my Imowledge. 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 identification and labeling of property lines and corners and locating and flagging
or �C@ ng hoes / ' ' location, proposed well location and the location of any other amenities.
Property owner's or owner's legal representative signature Site Revisit Charge
Date(s):
Client Notification Date:
Date EHS:
Sign given DYes []No
Revised 11/06
IV,
Account #
—�
Invoice #
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APPLICATION FOR :+ITE EVALUATION/IMP ROVEMENT PERMIT & ATC
)Davie County Health Department
Environmental Health Section HOP
P.O. Box &18/210 Hospital StreetMocksville,NC 27028
(336)751-8760/ Fax (336)7:51-8786
Application For. O Site EvatuetionMtBavement Permit O Amhorizat on To Conshvct(ATO O Both -
••?MPORTAANrP ' THIS APPLICATION CANNOTBE PROCESSED UPILESS ALL OF THE REQUB2ED
INFORMATION IS PROVIDED. Re:'er m tate INFORMATION BULLET:Y for instructions.
APPLICANT INFORMATION_'
QaI< Alt G q
Name to be Billed A -f o 4 ' Cortact Person
Billing Address P_a Hume Phone
City/State/Zll l . 2.� "� IOI BBusiness Phone_ Z^UD
Name on Permit/ATC if Different Ilan Above ^ .
NOTE: A survey plat or site plan must accompany this application
(Permit u vagd for 60 months with site plana, an expiration with coaplete plat.)
Street inion s�� -a�---City' Ti PI
Subdivision Name ay. �SectioM.o{ii ,�0.�ogf-S,i�u*_
Directions To Site:
u
Date House/Fscility Comets Flagged M A v,,L
If the amwer to any ofthe following questions is "Yes". supporting documcmatiopp mmtbe aczebed.
Are them any existing IMLAMrter systems on the site? OYta QtyiC
Dow the site contain jurisdictional wetlands? OYss Flo -
An there guy <ssemmm or right-of-ways on the site? OY: s BNo
Is the site subject to approval Sy mother public agency? OYs s ONO
—11 ....... he eemrated? OYza ONo
IF RESIDENCE FILL OUT TBI" BOX BELOW C ve t r n
#People #BedrXeM #'Sa ores Garde»Tub/WI»ripool OYes ONo
Basement OYes ONo Basse:nempl ing: OYes ONo
IF NON -RESIDENCE FILL OL"TTHEBOXBELOW -
Type of Facility/BusinessTotal Square Foolage of Building_ #People
# Sinks # Commodes # Sbowcrs _. _ # Urinals
Estimated Water Usage (gallons por day) (Attach doc,mrentation of similar facility water consumption)
FOODSERVICE ONLY: #Seals
Type systemrequested: WCanventioml OAccepted ❑lmovative OAltemative nOther.
Water Supply Type: Aunty/City Fater D New Well OFiisting Well O Community Well
Do you anticipate addition or expammm of the facility this system is intended to serve? O Yes 0<1
If yes, what type?
Ibis is to certify that lir infommation:,irovided on this application is true and correct to the best of my knowledge. 1 understand that
any permit(s) orATC(s) issued hared: are eubjeet m suspension m revue ation if the site is altered, the intended me changes, or if
the information submitted in this application is falsified or changed 1 undr atand that lam respansiblefor all charger inearred
from this application. I hereby grant right of eeny to the Authorized Rope aentative of the Davie County Health Departmeutto
conduct necessary inspections name compliance with applicable lava and rules an the above des�mibJjeed, �prroperty Wanted is
Davie unty, and ow,eeddbY^ ll/n%I• gSjB(.l Nf+'ir LI rI• Pw/n""'S�'n
t7onrc l,,w An Site Revisit Charge
EHS:
Sign given DYes ONO
Revised 2106
Account#
Invoice #
EM V LS
=APR6D
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Davie County He:
r.v.
(336)'
.May 1, 2006
Oak Valley Associates, Ltd. Partnership
Attn: Bo Davis
3401 Healy Drive
Winston-Salem, NC 27103 u
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 Server 4 82 QG51lit= Wastewater Design Flow: 4FC)
System Type: ❑Conventtionnal ?Jcepted ❑Innovative ❑Alternative ❑Other
System Location:I«= ibt7l� Valid: 2 'years ❑No Expiration
Site Modifications/Permit Conditions:
f 4-J1
inri
Enviro c' ist jDat
ps-i.p.letter 2/06
y
lz
3 Sq. Ft..l rotno9e Es
30,894
es_ dC:OUrSe Drive
SL. Andrews Golf Villas
n Section 98. Phate II, Section -2
Plot Book 8, Page 21
S Ft. Q I \Q e FI
Sq. • p\g° n
33,426 Sq. Ft.
9
\9s\
O
35,081 Sq. Ft.
E:1
, 148. _ =
4Ft. 243'88 5q. Ft.
270
ler0 co N I 16 I
w op i o
33,69 Sq. Ft.
, I
� zsa
Kassel I 17 '
n Kasselv,
igo 859 30,1 50 Sq. Ft. F1
^I
327
18 1 B
I
J 30,060 Sq. Ft. n
34,956 Sq. Ft.
la
35,486 Sq. Ft.
145'- 142'
"t— —♦
0
227'—
'Ii
a
�^ n
II !� 30,080 Sq. Ft.
0
30,080 Sq. R.
i
I
4 �I f
30, 74 Sc{. Ft.
� I 1
./A I
251
20
4th
m
erOw
J 30,137 Sd. Ft.
I
a1nPI 22'
>O1 626 ba dR�Csli _
9ht Of Ways 6�1
.1,,a1
LSI
T
30,078 Sq. Ft.
O
30,078 Sq. Ft.
in O
i 30.040 Sq. Ft.
237
O
I 31,107 Sq. Ft.
yl0
\P
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003765 Tax PIN/EH #: 5871-25-2458.03
Billed To: Oak Valley Associates Limited Partne Subdivision Info: Sawgrass Lot # 03
Reference Name: Bo Davis Location/Address: Beauchamp Rd -27006
Proposed Facility: Residence Property Size: see map Date Evaluated: 4112 -IOC -0
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
.FACTORS 1 2 3 4 5; 6 7
Landscape position LL
.'-,Slope %
HORIZON I DEPTH
Texture groupG. .. .' .G' -
Consistence
Structure S3 S3
-Mineralogy
HORIZON H DEPTH _ 30
Texture group
Consistence,
Structure g
Mineralogy.
-HORIZON IH DEPTH --7-7
Texture group O(S,L, 5;
Consistence
Structure yv\
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence .: ....
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON. •. _
SAPROLITE .,.,
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE p.
'SITE CLASSIFICATION: EVALUATION BY: ,
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
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 - Floodplain 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 ENCE
CONSIST I
,
VFR =Very friable FR -Friable FI -Firm
VFI -Very flim EFI -Extremely firm _
NS = Non sticky
Slightly sticky" S Sticky VS = Very la
NP - Non plastic SP' Slightly P -Plastic VP -Very pplastish
c
Structure
SC - Single grain M Massive, CR Crumb GR - Granular ABK -Angular blocky
SBK - Subangular blocky PL - Platy - PR Prismatic
•
MineraI6
:
1: 1, 2: 1, Mixed
Horizon depth - In inches
...
r d ,
Depth of fill'- In inches r = i
Restrictive horizon 'Thickness and inches from an surface 1
Soil Wetness - Inches)
n hes)from land surface to free water or inches from .' ;.
m land surface to soil colors wtt6 chroma 2 or less . .
Classification-,S(suitable), PS(provisionally;suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05105 (Revised)