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139 Essex Farm Road Lot 5Applicant: Address: city: State2ip: Phone n: CONSTRUCTION - AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 RS Parker Homes/Joy Springer 592 Hickory Ridge Dr Greensboro NC 27409 (336)978-7120 Address/Road 9: 139 essex Farm Rd Advance NC 27006 Structure: SINGLE FAMILY ;# of Bedrooms: 4 of People: 'Water Supply: PUBLIC / For Office Use Only "CDP file Number 158793-1 County ID Number: F8 -030 -AO -005 Evaluated For: NEW Township: 1 0/ 1 0/ 1 0 1 9 Property Owner: RS Parker Homes/Joy Springer Address: 592 Hickory Ridge Dr City: Greensboro State/Zip: NC 27409 Phone::: (336) 978-7120 Subdivision: Essex Farm Road Phase: Lot: 5 ("Site Classification: ProvisionailySuitable Saprolite System? OYes @No Design Flow: 4 8 0 Soil Application Rate: 0 a 7 5 'System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP 'Proposed System: 25% REDUCTION Directions Hwy 158, right on Hwy 801 S. right on Comatzer Rd. Pass School Essex Farm on right Minimum Trench Depth: a 4 Inches Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches `Distribution Type: PUMP TO GRAVITY Septic Tank: 1 0 0 0 Gallons 1 -Piece: OYes QNo Pump Required: @Yes ONo O May Be Required Nitrification Field 1 7 4 5 Sq. ft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 6 1 -Piece: OYes QNo Total Trench Length: 4 3 6 GPM -vs- ft. TDH ft_ Trench Spacing: - 9 Inches O.C. Feet O.C. Dosing Volume: Gallons g - Trench Width: 3 ()Inches - (W) Feet Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -11 Septic Tank InstallerGrade Level Required: 01 011 0111 OIV CDP File Number 158793-1 'Site Classification: Provisionally Suitable Design Flow: 4 8 0 County ID Number: F8 -030 -AO -005 @Yes ONo ONo. but has Available Soil Application Rate: 0 a 7 5 `System Classification/Description: TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP 'Proposed System: 25% REDUCTION Nitrification Field No. Drain Lines 6 1 7 4 5 Sq. ft. Total Trench Length: 4 3 6 ft. Trench Spacing: Trench Width: Aggregate Depth: Minimum Trench Depth: a 4 Minimum Soil Cover 1 a ❑ Open Pump System Sheet Inches O_ 9_ Feet O.C. Inches — 3 Feet inches Inches Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches `Distribution Type: PUMP TO GRAVITY Pump Required: @Yes ONo OMay Be Required Pre -Treatment: ONSF OTS -1 OTS -II `Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. 7( '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. 2( This Authorization for Wastewater System Construction shall bevalid for a person equal to the period of validity of the Improvement Permit not to exceed five years, and may be issued atthe sametime the Improvement Permit issued (NCGS 130A -336(11b)} If the installation has not been completed during the period of validity of the Construction Permit, the information submitted in theapplieation for a permit or Construction Authorization is found to have been incorrect, falsified or charged, or the site is altered, the permtt or Constr ctlon Authorization shall become invalid, and may besuspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible forassurirng compliance with the laws, rules, and permit conditions regarding system location, installation, operation, mahntenancg monitoring, reporting and repair (1936(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: Date: *Issued By: 2140- Nations, Robert Date of Issue: 1 0 / 1 0 / .2 0 1 4 Authorized State Agent: Malfunction Log OYes @Hand Drawing Olmport Drawing **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: 158793 - 1 County File Number: F8 -030-A0-005 Date: 10/ 1 0/.1 0 1 4 O Inch Scale: OBlock ON/A ., t APPLICAT SITE EVALUATION/IMPROVEMENT PERMIT &ATC Date: Davie County Environmental Health RECEIVED Received b : P.O. Box 848/210 Hospital Street r-tn Iocksville, NC 27028 Q (336)753-6780/ Fax(336)753-1680 9tdiii { Application For: , Site E�v luation/Improvement Permit _-'Autlmrization To Construct(ATC) Both Type of Application: 'z1Qew System -Repair to Existing System ':_Expaosion/Modification of Existing System or Facility "'*!iblPORTA:VP'- THIS APPLICATION CAAWOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFOILV[ATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed RS Ph4kcr D Contact Person lJGC ,Spr -i o er Billing Address O "7 r Home Phone City/State/ZIP (ternon5bG�n C 3-1401 Business Phone, 0 -I/(1) Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMA NOTE: A survey plat or site (Permit is valid f Owner's Name -5 Owner's Address Subdivision Namei Directions To Site: *Date House/Facility Comers must accompany this application. Included: 0 Site Plan —T.Plat(to scale) ahs wjtl site plan, no expiration with complete plat.) It the answer to any of the following questions is "yes", supporting documentation most be attached. Are there any existing wastewater systems on the site? =Yes .�.,,, C.' Does the site contain jurisdictional wetlands? =Yes a Are there any easements or right-of-ways on the site? ❑Yes o Is the site subject m approval by another public agency? ,Yes TVo Will wastewater other than domestic sewage be generated? -Yes o F b IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms t- # Bathrooms _� Garden Tub[4Vhirlpool Yes -No Basement: —Yes 'INo Basement Plumbinm: -]Yes VN. 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: ].(Conventional ='Accepted 'Innovative C'Altemative Water Supply Type:'IC,Cotmty/City Water G New Well ,Existing Well L Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? 7 Yes If yes, what type? �o This is to certify that the information provided on this application is tine and correct to the best of my knowledge. I understand that any pernut(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 carry 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 I izandlIlagging or staking the housc'facilay location, proposed well location and the location of any other amenities. Pr pe,4 own is or owneJs legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given ,Yes;—No Account # 6 Revised 11/06 Invoice G N07.32'00"E 100.00' SETBACK I I I I I I 4 I 5 I I y W N I b o � w I I � I I PROPOSED RESIDENCE II I SETBACK 0 un v — L 10' UTILITY EASEMENT N07. 2'00'E—+100.00' 00' ESSEX FARM ROAD 50' R/W (PUBLIC) GRAPHIC SCALE 40 0 20 w 80 ( IN FEET ) I inch = 40 ft SETBACKS FRONT: 45' SIDE 15' REAR: 30' r A�Na I 16 PROPOSED RESIDENCE HOME DIMENSIONS NTS PRELIMINARY 3 PLOT PLAN FOR. € RSP BUILDERS LOT 5 OF ESSEX FARMS, PHASE 1 w P.B. 9 PC. 289 r Rming Enginrnring, Inc. 8518 Triad Drive Colfax, NC 21235 Phone: 336-852-9797 ,: Fax: 336.852-9766 _3 e NCBELS C-0950 DATE 09-25-14 w REF: PROJ\1831-01\dwg\ESSEXFARM.dwg `` !� CATIA R SITE EVALUATION/IMPROVEMENT PERMIT &-ATC Davie County Environmental Health R. P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 uarmn/Improvement Permit 0 Authorization To Construct(ATC) 0 Both System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED u.....73 Name to be Billed 165C Ac'✓ *P",F-A77 c,4t, i ac Contact Person 7.'We t J -en u Billing Address A0.A.,x 3/o Home Phone City/State/ZIP .Jc. 27028 Business Phone 7S/- 7300 Name on Pemtit/ATC if Different than Mailing Address NOTE: A survey plat or site plan most accompany this application. Included: 0 Site Plan [3Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name �OSC /leVccoFiscNi Ccxz �rlG Phone Number 7S/-73� Owner's Address PO doj-10 City/State/Zip Nect%r wric' /--G 27028 Lot If -the answer to any of the following Guestionslis "yes", supporting documentatio99 must be aukhed. Are there any existing wastewater systems on the site? ❑Yes O'N� Does the site contain jurisdictional wetlands? ❑Yes 01io Are there any easements or right-of-ways on the site? [Kea ONo Is the site subject to approval by another public agency? Dyes Will wastewater other than domestic sewage be generated? ❑Yes C31Vo #People #Bedrooms !;6— #Bathrooms Garden Tub/Whirlpool OYes ONo Basement: OYes ONo Basement Plumbism: OYes []No 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: KConventional ❑Accepted ❑Innovative DAltemative []Other Water Supply Type: ❑'County/City Water 0 New Well DExisting Well O Community Well Do you anticipate additions or expansions of the facility this system is intended toserve? O 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 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 comers and locating an egging or staking the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge Props r�®roer's legal representa. re Dents): 7 Client Notification Date Date EES: Sign given OYes ONo Account# Revised 11/06 Invoice # 301.00' o0 � 30100 Sq.Ft. 0 1'✓YWAY Sp' " R. 0.691 Ac.+/- ustee S 82'-28'-00 oo' _0 .: 109.61= �r E � I N 301.00' ro ® Ca 30098 Sq.Ft. I b so 3 ^ 0.691 Ac.+/- o S 82'-28'-00" _ O _ I LL O li. E ^ co v N 307.00' ^ q. ^ N n O O N Oto ^ I Of N 30100 Sq.Ft. CD I n o c 0.691 Ac.+/- S 82'-28'-00" 0 E 301.00' " O © I rI w E � 30100 Sq.Ft. o 100.00• 9 82'-29'- o oo^. - 0.691 Ac.+/- O O I 9�1, 90.39' J � S82'- 28-00" E o 301.00' rp I ,. 30106 Sq.Ft. 3 z 3 } 'n0.691 Ac.+/- j ds 0 , I C 0 } o m •'f S 82'-28'-00" 0 0 �+ �+ w N¢ o - E -� N I M o N Cl) u o O r� p0 307.00' "� o 00 1 t o c0 N O I r \ 0 ® 30100 Sq. Ft. I M o co '? N7 o s1 N o r\ 0.691 Ac.+/- o + o { s2 00 o z S 82 301.000 E -_ I I� Jt 100.00`- 0 30100 Sq.Ft. -700.00'- 9/.65 0.691 Ac.+/- o d N 82•_28•- / 00 S 82-28'-00.. o ¢} 3 W C7 TYWAY 50''a S 82'-28'-00Ew (Public). E 301.00' �. - 126.2 8'_ 0 ® uwx C _ - 83.37_ R / 30100 Sq.Ft. w _ I 00 0.691 Ac.+/- o } S 82'-28'-00"E_ 0 o se w rn c?301.00' -1 to Z0 32070 Sq.Ft_ 69 N N �* oo 0.736 Ac.+/ ^ - 30001 Sq.Ft. � , n N 0.689 Ac.+/- ��oe9P1 � 3001.0 Sq.Ft. s 0.689 Ac.+/- ac`e`s � I K N n � Z �, C1, '- z N -�-` N1-30 -y L -sign esmt' 30'1"0 C2 JN CCRNA7 10 ,70 �C6-------C3--- 4.58 ase g, esme. SR 1616 ere o hydrant rve Radius Chord Bearing and Distance Arc Length 1599.37' N 74°-12'-50" W 304.15' 304.61' 1599.37' N 80°-33'-58" W 50.03' 50.03' 1599.37' N 87°-35-03" W 89.08' 89.09'- 35.00' S 59°-55-01"E 26.84' 27.55' 1 50.00' S 47°-48'-22" E 18.12' 18.22' 1599.37' N 83°-43'-31" W 126.31' 126.35 ' 35.00' N 74°-59'-02" E 26.84' 27.55' I 50.00' N 80'-23'-13" E 46.87' 48.79' 50.00' S 51"-10'-24" E 35.00' 35.76' 0 50.00' S 0'-11'-55' E 35.00' 35.76' 50.00' S 30°-46'-33" W 35.00' 35.76' 2 -50.00' S 86°-30'-33" W 57.71' 61.52' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004425 Tax PIN/EH #: 5870-64-2265.05 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 05 Reference Name: Brad Coe Location/Address: Cornatzer Rd -27006 Proposed Facility: Residence Property Size: 0.691 Ac. Date Evaluated: q- 1 <�_ cj7 Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit - aG - ®- f '15� wee eo'T �`J .P.K..� -e GYMS ✓ Public V O -A '7 FACTORS 14 /1-7 /16 1 4 5 6 7 Landscape position L_ L Slope % I i HORIZON I DEPTH p - (( tl - G - Texture group Sc -L S C' G Consistence Vir Structure lZ g iwly K` G nn 5 (� Mineralogy IN �- F� D S `- f9 HORIZON It DEPTH Texture rou ConsistenceStructure RL J`8Mineralo -W '5 - XP HORIZON III DEPTH 4 -Texture rou C Consistence Structure' Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE -- CLASSIFICATION LONG-TERM ACCEPTANCE RATE .' -7 5 - SITE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: �� 5 I -NUT t"41* l EVALUATIONBY: �A JJCI�cCVVa OTHER(S) PRESENT: 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 CONS ST�F.NCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Stet 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 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/112 DCHD 05105 (Revised) Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 **NOTE* *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, plat or the intended use change. Permit Type: MNew ❑Repair. ❑Expansion Permit Valid for: CaY Years []NoExpiration Residential Specifications: # Bedrooms q # Bathrooms # People_ BasementO Basement plumbing[] Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) - Design Flow(GPD):IWO Type of Water Supply: M-0`mity/City ❑ Well ❑ Community Well At stated in ILEA NC,�,C 1C.rt.w969(51 Site Modifications/Permit Conditions: Rceepted Systems may aipo be usecr System Type LTAR Initial RePau5— sim Plan hof IMPROVEMENT PERMIT Account #: 990004425 Tax PIN/EH #: 5870-64-2265.05 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 05 Address: PO Box 340 Location/Address: Cornatzer Rd -27006 City: Mocksville Property Size: 0.691 acre Reference Name: Brad Coe Proposed Facility: Residence **NOTE* *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, plat or the intended use change. Permit Type: MNew ❑Repair. ❑Expansion Permit Valid for: CaY Years []NoExpiration Residential Specifications: # Bedrooms q # Bathrooms # People_ BasementO Basement plumbing[] Non -Residential Specifications: Facility Type # People # Seats_ Square Footage(or Dimensions of Facility) - Design Flow(GPD):IWO Type of Water Supply: M-0`mity/City ❑ Well ❑ Community Well At stated in ILEA NC,�,C 1C.rt.w969(51 Site Modifications/Permit Conditions: Rceepted Systems may aipo be usecr System Type LTAR Initial RePau5— sim Plan hof �, TT �o 301 Environmental Health Specialist Date tlA Phone: (3336) - 753- 6780 Davie County Health Department Dzvironmental Health Section v P.O. Box 848 C� 210 Hospital Street I. Courier # : 09-40-06 4� Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement emadeyn Reconnection Fav (336) - 753-1680 Name: eowkYl Phone Numbergcm 54- g--"5 3 (Home) Mailing Address 2mo` C\ o({ i i- Y, 9 t g (Work) ArAyccriCe mc Email Address:lCAtrE6t —I- _ kWW -1 @ loVVeC• CSL! Detailed Directions To Site: 43 C- Corior 4 7--e,- Qck Property Address: (ScC sf2 x T-ck lez� A -A ~VCe. A/C o� 1CJ�7 Please Fill In The Following Information About The EXIST)NG Facility: Name System Installed Under: (?-'S S Type Of Facility: 4Wgk k R.�27k C �;fn"Date System Installed (Month/Date/Yeaz): 'ZO(���Rn'yJt4� Number Of Bedrooms: `71 Number Of People: Is The Facility Currently Vacant? Yes E") If Yes, For How Any Known Problems? Yes If Yes, Explain: PIease Fill In The Following Information About The NEWFadlity: Type Of Facility: .( ia-t oC cid 0 5 4CQa dt0. Number Of Bedrooms:Number of People Pool Size: u 1 n CTa.ge Size: ' e- Other: Requested By:4yaO I Li Date Requested: For Environmental Health Office Use Only Disapproved III Environmental Health SDecialis�-7�/f //%/-- i Date: f,� — S -/- the En'rdonmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function property for any given period of time. Payment: Cash Check Money Order 4 Amount$. Paid By: Received By: Account #: Invoice #: