155 Alamosa Drive Lot 13 (2)Davie Countv, NC ,
_ T� Parcel Report
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Parcel Number:
NCPIN Number:
Account Number.
Listed Owner 1:
Mailing Address 1:
City:
State:
2ip Code:
Legal Description:
Assessed Acreage:
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
Wednesday, October 12, 2016
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WARNING: THIS IS NOT A SURVEY
Parcel Information
G80000000504 Township:
5870347123 Municipality:
Shady Grove
58158000 Census Tract: 37059-803
POTTS REAL ESTATE INC Voting Precinct: WEST SHADY GROVE
C/O DIANE H POTTS Planning Jurisdiction: Davie County
ADVANCE Zoning Class: DAVIE COUNTY R-A,R-20
NC Zoning Overlay:
2700Cr0498 Voluntary Ag. District: No
15.042 AC LA QUINTA DR Fire Response District: ADVANCE
14.97 Elementary School Zone: SHADY GROVE
La�d Value:
Totat Assessed Value:
9"�`�' Davie County,
`'��N�� NC
8/1996 Middle School Zone: WILLIAM ELLIS
001890012 Soil Types: GnB2,GnC2,GaD,MsC
Flood Zone:
Watershed Overlay:
0.00 Outbuilding 8� Extra
Freatures Value:
87120.00 Total Market Value:
96120.00
DAVIE COUNTY
96120.00
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aAUTH��RIZA'�ION NO. ' ���� DAVIE COUNTY HEALTH DEPARTMENT
,��' �" .;:�� � " Environmental Health Section PROPERTY INFORMATION •
Permittee's �; P.O. Box 848 �,�.��,,�,-t,,.n ,�,..�''�. ��Z�r.:`��...
Name: _; � � . :' Mocksville, NC 27028 ; Subdivision Name: (1rw-r--. �^-t��'�� ... ci�'s�
� ,� Phone #: 704-634-8760 �,� �� �., �,
Directions to property: /; J,� '� ; C: r...�i Section: Lot: �
AUTHORIZATION FOR
WASTEWATER �f ''''r! j") �t
SYSTEM CONSTRUCTTON Tax Office PIN:# �� F� -�`�' - 1� c:i �
Road Name: � � [?E-'Yi1or;� ��F Z�p: �,:���4�
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pemuts. This Forn�/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
J,�� ;,...-7 ,,. .;� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
.�- �' {;� .��;; ��� ��/i'~�,�,`�,,� , (` �fr_ /f ;>%' IS VALID FOR A PERIOD OF FIVE YEARS.
b`NVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
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•: ���, -j, - DAVIE OUNTY HEALTH DEPARTMENT
� 4��: '- �.-} iI�JPROVEMENT AND OPERATION PERMITS PROPERTY I�FORMATION . •�
Permittee'rs �� ��" . /� fi.= � � ,k, , r � � `^ �� .� ,�� •� _ ,
( �_" � .� f;.. .r , L "'X�, , , �5 - �.s r .�.,t ti-�
Name: -� �. �'}.� .o-J t�" `f ��!�.+'f ^-"� 7 /ri'�i�l`� �,� Subdivision Name. f,�("? �" ��"3 `'"`.`"%''1.. C�!^ -
� � .
, � � _ .�'�' , Section: " Lot: � �f�;..z: tx.w=�r.:...
D'}rections to property: �'' .�< ;- , � ,9
� IlNPROVEMENT _ ,
' _ PEItMIT Tax Office PIN:# �C 1�� � `'i' �� � �� ''�
� �
Road Name: �� �,:i.�� fC�::t�� ��'`' Zip: � ���,f,�,,
**NOT'E** This Improvement Pernut DOES NOT authorize the construction or installation of a septic tanlc system or any wastewater system. An
` AUTHORIZATTON FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Secrion .1900 Sewage Treatment and Disposal Systems)
'' ---"? =;, �'.� � , „ , ***NOTICE*** THIS PERNIIT IS SUBJECT TO REVOCATION IF SIT'E .
� � ,��/''� •�;'S ,,.r`';,„-,�_ �' s,r�i , "( ' � • /�' ;•' .,' PLANS OR TFIE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
. INSTALLING TI� SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEDROOMS ts� # BATHS `� # OCCUPANTS _� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE. ��� TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) �� � NEW SITE �d REPAIR SITE
i/ � � t�
SYSTEM SPECIFICATIONS: TANK SIZE ?� GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH .IJ LINEAR FT. —rt'' �
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
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AUTHORIZATION NO. /D 1'Z OPERATION PERN
SYSTEM INSTALLED BY:
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**THE ISSUANCE OF THIS OPERATION PERMTT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECI'ION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
APPLICATI'ON FOR SITE�EVALUATION/IMPROVEMENT
• Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704)634-8760
� ���� a � �
JUL 2 1 19�7
'�***IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed L � Contact Person �d'�l L/-G %�
Mailing Address � � Home Phone
City/State/Zip � /'��1�ei� /"�.0 . `�-%6� �P Business Phone �� � � �ZJ
2. Name on PermidATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [/] Site Evaluation �rovement Permit & ATC oth
4. System to Serve: [] House [ obile Home [] Business [] Industry [] Othe -
5. If Resi nce: # People� # Bedrooms � #� Bathrooms �-- [ Dishwasher [] Garbage Disposal
Washing Machine [] Basement/Plumbing [] Basement/No Plumbing
—�.
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: [] County/City [] Well [] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ J Yes No
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: ��� � WRITE DIRECTIONS (from Mocksville) TO PROPERTI':
Tax Office PIN: # � ! � - �T - < �o�{ 3 ! G �" L �!
Property Address: Road Name i� �. fi'I�V1 �,t�- bl�, ��� %� /�i �C� �� �� � F% ds��—
City/Zip f� ��� /✓�� • 2 7�3c0� .� .Z�' U d/l/�-
If in Subdivision provide information, as foliows: �;� nr e�� rl �lr'�,L r+u`. . Ti! N 2X L C. FT �`
Name: 5�' � yt/`,� Z l� l�Ut1ll' i i�� � �� �� S' ' f3 L�} ✓YL U� R
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Section: � Lot #: �
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This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Repre tative of the Davie County Health Department to enter upon above described property located in Davie County and owned
by�<���� �2RL �,�Tjg-Te �1�4-��nduct al},�e��Eed�es as necessary to determine the site suitability.
6
Revised DCHD (06-96)
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PARCEL 2
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• � � ' � � DAVIE COUNTY HEALTH DEPARTMENT
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,: �� Environmental Health Section SECTION LOT
SoiUSite Evaluation
APPLICANT'S NAME �Fi �S DATE EVALUATED a r/� �f" /
PROPOSED FACILITY � PROPERTY SIZE J J��'i
SUBDNISION ROAD NAME �,����?7S�/'
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut_
HORIZON II DEPTH
SITE CLASSIFICATION: EVALUATION BY: �Y� !'�
�
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 - 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
Moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wet
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
Mineralogv
1:1, 2:1, Mixed
Notes
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 (01-90)
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^au��o��?�'rIorr No: ���� DAVIE COUNTY HEALTH DEPARTMENT I/� s�
�,� »: :: ,,� '�nvironmental Health Sect�on � PRO�ER� INFORMAT ON
Permittee's � , {�� ` a�; �,� .�� � ' � P.O. Box 848 j,:.��-��"Zt��� �-� '.1't`�e' /�1•� �r�-�.
�ry �. �; e, �'
- - ' Name: ' - �� �'��r�r ��""' ��,�'���� �'� �� Mocksville, NC 27028 ,� �' �ubdivision Name: �1�� � �-�:�' � "'�--r.C�'�.-
� ' � � Phone #: 704-634-8760 ' / • ' ��`1/1r�IL
Directions to.property: /��;''r �� (�..��i` Section: Lot: �' �'���-- n
' AUTHORIZATION FOR )
WASTEWATER Tax Offce PIN:# ����- '� �� - ���7 �
SYSTEM CONSTRUCTION
Road Name:1`�f �-i'►'2 D��.-�" Z�lp; �70 � tcJ
**NOTE** This Authorization for Wastewater System Constcvction MUST BE ISSLJED by the Davie County Environmental Health Section prior
to issuance of any Building Pemuts. This Fotm/Authorization Number should be presented to the Davie Counry Building Inspections
O�ce when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
� ,% < ,�. ***NOTICE*** THIS AUTHORIZATTON FOR WASTEWATER CONSTRUCTION
��' �iY,•5���,1`f `-�'.''f��� �,�/} ,�' /"�� "'"` r7 ' IS VALm FOR A PERIOD OF FIVE YEARS.
�_�-
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
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,. :�i ° � r ', +� � �I � �G � �,»if4� �`` 1';a •, '��* &' i� u
' ! r ,: �. � DAVIE COUNTY HEALTH DEPARTMENT // • `�
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4 ��'' ��`' . _ IMPROVEMENT AND OPERATION PERMITS PRO�ER�'Y INFORMA'�ION
Permittee s j� � � �t'� : �.. / # r ,� :+°„y � { '7, "r+ ' �{"�•.�': v }� !^f� �� rn � �_.,,,
%r` �' r� t �.C.. y c,�::.�'�. �5
t.. t' � r^ .. . i T s }
.,,. . Name: �,' ,� „f4.'".� r.:°� ��`� �,���' �.�:; ° � �SubdivisionName. �.r?_�� f, 4, .:�.Lr�;
�_ R.= . � µ � ��
E. r< ,E:.� -�:�j��.�...
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Directions to property: � r`: �' A" �, Section: Lot: "' =' �r '"•� •---- f•��^^°
IlVIPROVEMENT f-3i, . .r" .� t , .y--
PERMIT Tax Office PIN:# � �� �f - "� �� � - ��-;:j �3
Road Name .; ° �,{�'� 'r ; � Ca P' �. ��"�'Zip: � `; �" ;�. �,� ��, .
**NOTE** This Improvement Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained fram this Department prior to the
constntction/installation of a system or the issuance of a building pemut. '
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) :
'` '+ r;. ' `' ***NOTICE*** THIS PERNIIT LS SUBJECT TO REVOCATION IF SITE
�,,� � �y r Yt 5 �! �, , ✓� �,..:,1 .�„ ` � ..r�
E,' ;1 < f., • ;F'i PLANS OR TI-IE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE-ISS D SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
�
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �% # BEDROOMS LS # BATHS � # OCCUPANTS � GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLFISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE ����� TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) --s �? � NEW SITE '�'��- REPAIR SITE
� � � �,
SYSTEM SPECIFICATIONS: TANK SIZE !l% GAL. PUMP TANK GAL. TRENCH WIDTH �= f ROCK DEPTH •`-� LINEAR FT����� �
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PExtµIT LAYOUT
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR I:00 - 1:30 P.M. ON THE DAY OE INSTALLATION. TELEPHONE # IS (704) 634-8760.
I OPERATION PERMIT
� G�rA-le�
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SYSTEM INSTALLED BY: .1�h n w ��
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AUTHORIZATION NO. I(/ l OPERATION PERMIT BY: DATE: Q��� ��
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE T THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAP'TER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
r
• . APPLICATION FOR SITE EVALUATION/IMPROVEMENT
'. ' h Davie County Health Department
' Environmental Health Section
� � " � P.O. Box 848
< Mocksville, NC 27028
(704) 634-8760
D 5 �Jw,�i� .i�..�„�„�
AUG I I I997
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �O l �J �� � � � �'Q- �N�Contact Person � � a
Mailing Address � �� 6'�0_� � ��✓ �i.u�_��J/'F� i Home Phone
City/State/Zip �ldv��{,1 /1� C-� '1-7d C''�D Business Phone � % O .� � �
2. Name on PermibATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [r ] Site Evaluation [] Improvement Permit & ATC �th
4. System to Serve: ,[ ] House [�'�Iobile Home [] Business [] Industry [] Other
5. If Residence: # People� # Bedrooms � # Bathrooms oZ [�shwasher [] Garbage Disposal
ashing Machine k] Basement/Plumbing [] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: County/City [] Well [] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [] Yes �
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
+
� SUBMITTED WITH THIS APPLICATION.
Property Dimensions: � 3 �� ��• ; WRITE DIRECTIONS (from Mocksville) TO PROPERTI':
Tax Office PIN: # �0 7� - - 7l � � ! �-
Property Address: Road Name /� l. I� � b,� �i Di�. �
�
' .C�cy�z�P �1 d✓s•�ri.��_ �1 C. a?e s�e ; �t,d ,.��,-�.�
If in Subdiyision provide information, as follows: � �� �r- �2i-e��lL
� i.. /�S"� JE1 d�l •
Name: �
� �p � �—�r��
Section: Lot #: �/�tie,G�-OtL.� l9�c.... % C'i h T � r Fa�
, �- .
This is to certify that the information provided is correct to the best of my knowledge. I understand that any pertnit(s) issued hereafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incuned from this application. I, hereby, give consent to the Authorized
Represe tative th avie County Health Department to enter upon above described property located in Davie County and owned
by_� , F. to c uct all t'�p dures as necessary to determine the site suitability.
� ���
DATE �-- /�— � �_ SIGNATURE _
) �
Revised DCHD (06-96)
3���
�
�M � ��
1� r �t
, _ �� ,� ., � • DAVIE COUNTY HEALTH DEPARTMENT
' . • Environmental Health Section SECTION LOT
� Soil/Site Evaluation
APPLICANT'S NAME ''� �� DATE EVALUATED B�' �.3 6�
PROPOSED FACILITY PROPERTY SIZE f� `S �9C
SUBDIVISION ROAD NAME � �i.��'ll S/-r
Water Supply:
Evaluation By:
On-Site Well Community.
Auger Boring f� Pit
Public �/
SOIL WETNESS
SITE CLASSIFICATION: �� EVALUATION BY: �6�
LONG-TERM ACCEPTANCE RATE: ) 7 OTHER(S) PRESENT:
REMARKS:
DCHD (O1-90)
LEGEND
Landscape Position
R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope
CC - Concave slope CV - Convex slope T- Tenace 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
Moist
VFR - Very friable
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firrn
SS - Slightly sticky S- Sticky VS - Very Sticky
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
Mineraloev
1:1, 2:1, Mixed
Notes
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
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AUTHQRIZATION NO: ���� DAVIE COUNTY HEALTH DEPARTMENT
'' w'`� "` Environmental Health Section .P OPERTY INFORMATI N
- Penr►ittee's � P.O. Box 848 �o�"����Q.1'Y1�;�,�7 � � ``"'��' �`A -� f � ^-
r
,/�'�`,�� � �,. t� � �.�'
}� �,
N�ne: +� �� �t� �i Mocksville, NC 27028 . Subd�v�sion Name: 'i..�+'1�'s? t...� r �:"'
/+ �/ Phone #: 704-634-8760 ��'�-�'—'_' �:"w-- 'L...;,�^";�'
Directions to property: C{'.-����'�%i��1C�L� �r' Section: Lot: �'a �.� , p�
AUTHORIZATION FOR j .�}
WASTEWATER ���c�}_ �'`�� _ �l�O'� '�
' SYSTEM CONSTRUCTION Tax Office PIN:# �
Road Name: �' ± �G'�-7''�� D����d t�
**NOT'E** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Sys[ems, Section .1900 Sewage Treatment and Disposal Systems)
/ /•.-� i^ '� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
f� `�'` %/ IS VALm FOR A PERIOD OF FIVE YEARS.
,t.r •�' i�� �.'1'^i , y', / .,�
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
.; �. f S �. - - � ' • ' .. . � � �,� r� . -, . . . . . .. _ _ . . . � � .. � . . - . . . . � �.��..+� `'� j �I l,/
�;. , —" i'! f' �" �""y L� �.. � .���� �',� � ,• �r ��
.. "'� '.-- ���. �f � � �.d'.
- �,�-�� , �: �,-� . , DAVIE COUNTY HEALTH DEPARTMENT
`�'� t k;': �, �� INfPROVEMENT AND OPERATION PERMITS � P OPERTY INFORMATION
Permitte�.'s :��,..� � � ��r�" .�^ � �� � ��.� �.w. ��� ,�. �� � �.� �r` � `� � � �� 6� �''� �_ y �,,
� ,,,.. - . . f�, �� � � n,rt �`.,_ � �, •::: . �` ' � y ,
Na�:ie: �` �.° t` t,.�.4 .....,�,,, a,; , f� ,- f,� ��'.»�
Subdivision Name 4i°t� .���,. -.� W ��.•
' ^ „ e`...,i�.. ; ti„cw? . �'.`- , ,, !a� � � r.,
.
Directions to property: �.. ' � Y'` 'r � � f ` ��f Section: Lot: �`'� t' � � `-' ^ r"'
IMPROVEMENT �'.,� ,� • � �',+ , -,-
PERMIT Tax Office PIN:# '� ���- `�''� �� �`+�t��`� �'�
� �L.=-''Y`1 � L;'�'Gt. °"'l�.�.''`°�; r�`z!}�j��
Road Name: � -� Zip: �= � `
**NOTE** This Improvement Pernut DOFS NOT authorize the construction or installation of a sepdc tank system or any wastewater system. An
AUTHORIZAT'ION FOR WASTEWATER SYSTEM CONSTRUCITON must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
�..•` ,•:' ,.� ,- �, �, .,; �° r-y w. ***NOTICE*** THI.S PERNIIT IS SUBJECT TO REVOCATION IF SITE
1 j' t t: ''.''; � i==r* ; r`%.., �i i r"� %�;�` � PLANS OR THE IN'I'ENDED USE CHANGE. YOUR WASTEWATE`R
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THLS PERMTI' BEFORE
INSTALLING Tf� SYSTEM.
RESIDENTIAL SPECIFICATION: BUII.DING TYPE �# BEDROOMS� # BATI-IS �# OCCUPANTS � GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILTTY TYPE # PEOPLE # PEOPLF/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT S� a���" TYPE WATER SUPPLY ( U DESIGN WASTEWATER FLOW (GPD) �. SjL% (� NEW SITE �/� REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE ��� GAL. PUMP TANK GAL. TRENCH WIDTH —?t% �� ROCK DEPTH _�� LINEAR FT.�.'S�U� f
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
..
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
�/-r5'9 �
�b �a
/
� � -? �
; 2�
' � � ^ ��
� �1� �, 3
AUTHORIZATION NO. � OPERATION PERMIT BY: DATE: ��` ��
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
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APPLICATION FOR 5ITE,EVALUATION/IMPROVEMENT PERMIT & ATC
*'�'�'� I MP O RTA N T****
, Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704) 634-8760
THIS APPLICATION CANNOT BE PRO
THE REQUIRED INFORM�iTION IS PROVIDED.
1. Name to be Billed /�G� ��G �� l/f"�G ibFtL, Contact Person � fi�
Mailing Address �� ��� �� Home Phone
City/State/Zip ���4N �L/✓ �. a�70�.p Business Phone ��l ��-/ �%l%
2. Name on PermidATC if Different than Above _
Mailing Address
3. Application For: [] Site Evaluation
City/State/Zip
] Improvement Permit & ATC [ oth
4. System to Serve: [] House obile Home [] Business [] Industry [] Other
5. If Residence: # People� # Bedrooms � # Bathrooms ?� ishwasher [] Garbage Disposal
�shing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats timated Water Usage (gallons per day)
7. Type of water supply: [ County/City [] Well [] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [] Yes [�
If yes, what type?
PROPERTY INFORMATION RE UIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
f! 7� �/t3 G SUBMITTED WITH THIS APPLICATION.
Property Dimensions: ����� � WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
�Tax Office PIN: #�� - 3`T' -� ; G� E K "fD L d�'�
�
Property Address: Road Name A� R in o Si� D�_ � t� f� . �C 6r�-�
c�cyiz;P � d t� A� �(! !.� N L. �eo("q ' 7z� L
If in Subdivision provide information, as follows: � �� S' � T��
Name: ��/' ►4 ✓ e.li �� •� A T�ivd� J G
�
Section: Lot #: �
This is to certify that the information provided �s correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsifed or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative of th Davie C unty Health Department to enter upon above described property located in Davie County and owned
by �� z:QJ4�� �. � t n uct all te ' s as necessary to determine the site suitability.
DATE g� I1— 9,� SIGNATURE
Revised DCHD (06-96)
• ., � • DAVI� COUNTY HEALTH DEPARTMENT
' Environmental Health Section SECTION LOT
' SoiUSite Evaluation
APPLICANT'S NAME !� (Z � S DATE EVALUATED �'/3��
PROPOSED FACILITY PROPERTY SIZE � �/�'i
SUBDIVISION ___ _ ROAD NAME
Water Supply: On-Site Well Community
Evaluation By: Auger Boring 1/ Pit
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
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 ACCEPTAr
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE: ��
REIVIARKS:
DCHD (01-90)
Public !/
Cut
EVALUATION BY:
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
Moist
VFR - Very friable
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
SS - Slightly sticky S- Sticky VS - Very Sticky
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
MineraloEv
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fll - 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 - gaUday/ft2
■■■
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