295 Armsworthy Rd (2) DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Account #: 989900057 Tax PIWEH#: 5861-76-1069
Billed To: Randy Grubb Subdivision Info:
Reference Name: Kevin Adams LocalioniAddcess: 295 Armsworthy Road-27006
Proposed Facility: Residence Ptoperty Size: 1.073 Acre
ATS*WMThe?ssuance of this Operation Permit shall indicate the system described on the ATC 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.
t �+ �-y Q
System Type:A 9 S.T.Manufacturer<9CJ� Tank DatTank Size d
Pump Tank Size toPO - 7//0
System Installed By: 0AU E.H.Specialist: ate: 2D(
GPS Coordinate:
tj
J
11
r-
�y
DCHD 11/06(Revised)
' DAVIE COUNTY ENVIRONMENTAL HEALTH
•�' P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
1 (336)753-6780/Fax#(336)753••1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 989900057 Tax PINIEH#: 5861-76-1069
Billed To: Randy Grubb Subdivision Info:
Reference Name: Kevin Adams LocationiAddress: 295 Armsworthy Road-27006
Proposed Facility: Residence Property Size: 1.073 Acre
ATC Number: 5752 Site Type: D94ew DRepair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change.
Residential Specifications: #Bedrooms #Bathrooms-3-4 People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size 1.073 OL Type of Water Supply: ❑County/City W4-Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)—TCO—Tank Size GAL.Pump Tank_Lt /�J AL.
Trench Width pMax.Trench Depth�d Rock Depth,00 Linear Ft. "1 25%
Site Modifications/Conditions/Other: ICeU n
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30-9:30a.m.on the day of installation. Telephone#(336)751-8760.
too
qft T `�
- t
Po
i
Environmental Health Specialist Date:V_
d /
DCHD 11/06(Revised)
APPLICATION FOR SITE EVALUA'70N M"ROVEMENT PERMIT& ATC
C E I V E Davie Covftty-Enviroaamental Healtbl
1011 P.O.Bo*848/210 Hospitrd Street
KAR 14 Mocksville,NC 27028
(336)753-6780/Fwa(336)751-8786
Application For. J Site Evaluation/Improvement Permit Pf Authorization To Construct(ATC) 0 Both
Type of Application: PtNew System ❑Repair to Existing System CJEagmsion/Modification of Existing System or Facility
***Ik*PORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed InyMn Contact Person IuLJ
Billing Address /30 Home Phone
City/State/ZIP mockswildaBusiness Phone
Name on Permit/,ATC if Different than Above
Mailing Address City/Stato2ip
PROPERTY INFORMATTON *Date House/Facility Corners Flagged qllv
NOTE: A survey plat or site plan must accompany this application. Included:U Site Plan [.[Plat(to scale)
(Permit is valid for 60s with site plan,•no expiration with complete plat.)
Owner's Name itdQ Phone Numbet
Owner's Address er City/Statelzip
Property Address City. Aiyane&f /V '7006
Lot Size 1,fi TaxfPIN# 59 71P 10 42
Subdivision Name(if applicable) Sectiott/Lot#
Directions To Site:
4
If the answer to any 6fd4 following questi is"yea",supporting docunicnifition ust be attached.
Are there any existing wastewater systems oo the site? ;.[Yes jiNo
Does the site contain jurisdictional wetlands? ❑Yes I(No
Adz there any easements or rWof ways oo the site? UYes 19No
Is the site subject to approval by another public agency? I(Yes❑No BwWr'l,
Mfl-
Will wndc*atar other thao domestic sewage be genetatod7 UYes QINo
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms _13- - #Bathrooms Garden Tub/Whirlpool Oyes )rNo
Basement: C.iYes o Basemcot Plumbing: nYes ANo
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 UAccepted Ulrwovative L)Alternative 00ther
u
Water Supply Type: Ll County/City Water New Well ilExisft Well U Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes Ar No
If yes,what type.
VA W%,A,"VW AAHYAYA 11.,FWKAµ AN W WI/YYA.•AAWVJOMA�YY7wN�Wi►V{AYWAAU/NW WUAtAAAMUW-.YA NlA,IAN.AWAY AYtta NUM P"WO. -
1 understand that I am msponsibie for the proper identification and labeling of property lines and corners and locating and flagging
or sbdgpg the b foci ' 1 ation,proposed well location and the location of any other amenities.
Property a 's or owner's legal reprzsentatn►e signature Site Revisit Charge
L?lj Q�(s)
Client Notification Date:
bate EHS:
Sign given 1:)Yes ONo Account# [_O / l 00 7
Revised 11/06 Invoice# V/_
/VO 6
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 990005537 Tax PIN/EH#: 5861-76-1069
Billed To: Robert Spillman Subdivision Info:
Address: 448 Baltimore Rd Location/Address: Armsworthy Road-27006
City: Mocksville Property Size: 1.073
Reference Name:
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: (ZNew ❑Repair ❑Expansion Permit Valid for: A5 Years ❑No Expiration
Residential Specifications: #Bedrooms, #Bathrooms #People Basement❑Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(ot Dimensions of Facility)
Design Flow(GPD): �y Type of Water Supply: ❑County/City &Well ❑Community Well
�ite Modific ions/Permit Conditions:
,��� co US
System Type LTAR
Initial r, V4A)9Jicn I . 2
Repair 2gi& oh I Z
Site Plan
UJ
0
1
Environmental Health Specialist Date
i.p.11-O6
APPLICATION FOR SITE EVALUATION/IMPROVEM F -�
Davie County Environmental Health
P.O.Box 848/210 Hospital Street ! JUN 2 4 2010
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680 ENVIRONMENTAL HEAUH
DAVIE COUNTY
Application For: P09ite Evaluq ion/lmprovement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type of Application: ❑New System ❑Repair 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 Contact Person ,jQ%f,�y,�+a✓
Address Home Phone f f k-VA 7/ '
City/State/ZIP A&aaa NL zgmk Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name�f �L •/%�,✓ Phone Number 9 t*- T/
Owner's Address Ae City/State/Zip_^V11. ?MV4,
Property Address City4th". Z 7a4,
Lot Size 4 7.? Tax PIN# Sib/- ?b• /OG 0
Subdivision ame(if applicable) Section/Lot#
Directions To Site: &rp PAJT / / t�Z� zK
If the answer to any of the foflowing questions is"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? _Yes 'e�No
Does the site contain jurisdictional wetlands? _Yes /bio
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 o
IF RESIDENCE FILL OUT THE BOX BELOW
#People ' 3 #Bedrooms .9 #Bathrooms Garden Tub/Whirlpool ❑Yes J.Rio
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑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: FT6`nventionalccepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:❑ County/City Water kNew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes e-1110
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 corners and
loc ting and flagging sta ing the house/facility location,proposed well location and the location of any other amenities.
i
Site Revisit Charge
'rop rty owner's or owner' legal representative signature
Date(s):
ayyo Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# '553-7
Revised 11/06 Invoice# 7357
b-f LeA•sv
.R.
APPLICATION FOR SITE EVALUATION/IMPROVEMFM PERMIT&AT D R u n U M
R
Davie County Health Department
Environmental Health Section MAR 2 ( 2000
P.O. Bos 848/210 Hospital Street
Mocksville, NC 27028 ENVIRONMENTAL HEALTH
(336)751-8760 DAVIE COUNTY
***IMPORTAWZk** THIS APPLICATION CANNOT HE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1.
1. Name to be Billed Contact Person �"i,Y
.Mailing Address Home Phone [�� 90-71
City/state/ZI'e Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4. system to service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other _
5. If Residence: # People3 # Bedrooms _ # Bathrooms
Q Dishwasher fJ Garbage Disposal [Ywashing Machine 11 Basement/Plumbing [.I Basement/No Plumbing
6. If Business/Industry/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 PWell ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑No
If yes,what type?
-v'a�E ,'IN G—MV
-UTiON REQUES—AVID
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. ,
Property Dimensions: �l 1 1� �-L�LQ�. WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: #- 11CV
Property Address: R u risme
city/zipdvc
If in a Subdivision provide information,as follows:
Name:
Section: Block: Lot: Date Prope Flagged: �Jam,��UD
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 Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE ``�= ted SIGNATURE ")t:tiL�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
S Site Revisit Charge
P Date(s):
as � Client Notification Date:
EHS•
O�
Account No. /J
Revised DCHD(07/ Invoice No.
o
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001056 Tax PIN/EH#: 5861-76-1069
Billed To: Maxine Spillman Subdivision Info:
Reference Name: Maxine Spillman Location/Address: Armsworthy Road-27006
Proposed Facility: Residence Property Size: 1.073 Acre Date Evaluated:
Water Supply: On-Site Well Community Public '
Evaluation By: Auger Boring '� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 3 `'
Texture group
Consistence
Structure /
Mineralogy ! Al
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 i
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: i 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
Mois
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
Mineralogy
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 05/99(Revised)
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--• ....- rs;t^. ..v.-+ea,e-.x-a'^-cvT.r<a.-:.:_-..;.,.�r..n^•�!.4:'i!Air.r:..?^F".'-4:mi*^a"T4.`}.w•4,:w.le�F?'.:T2'rrr--v r•^-..<. .._
DAYIE COUNTY Ii LTH Rg?AR! 6 W
ENVIRONMENTAL HEALTH SECTION
P. O. Box 848/210 Hospital Street
Courier #09-40-06
Mocksville, NC 27028
Phone #: (336)751-8760
April 18, 2000
Maxine Spillman
448 Baltimore Road
Advance,NC 27006
Re: Site Evaluation/Armsworthy Road
Tax Office PIN: #5861-76-1069
Dear Client:
As requested, a representative from this office visited the aforementioned site on
April 17,2000. Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, the site was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions,please feel free to contact this office.
Sincerely,
AA$t-r'e. �.
Robert B. Hall,Jr.,R.S.
Environmental Health Specialist
RH/mp
Enclosure(s)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990005537 Tax PIN/EH#: 5861-76-1069
Billed To: Robert Spillman Subdivision Info:
Reference Name: Location/Address: Armsworthy Road-F7006
Proposed Facility: Residence Property Size: 1.073 Date Evaluated: t� 2
Water Supply: On-Site Well o�_ Community Public
Evaluation By: Auger Boring Pit /L' Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L, [ ( k t
Slope% % -g oa
HORIZON I DEPTH p 1>410
Texture group l [, C _ C
Consistence y
Structure
;V-
Mineralogy I; t
HORIZON H DEPTH
Texture groupL
Consistence
Structure AwAk AA_
Mineralogy ( �1 ;1
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: a EVALUATION BY
LONG-TERM ACCEPTANCE RATE: 2 OTHERS)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
WEI
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
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)
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47
I NAR ,
VICINITY MAP
PAUL MCC
W � D.B. 54 ULLOH o `�
PC. 495
bD.B. 49, PC. 55 d
D.B. 138, PG. 819
D.B. 170, PG. 5,21
P.I.P --� 24'
N.I.P
S 83.33'03' E PAVED
f-
W _ 350.81 y
CD -------- -------CD L&j
_____ S 83.33'03•
__
v' AR FA= 1.073 AC. - 20-PROPpSED EASEMENT__49 -- --__-FENCE LINE -_- NIP_ S 83.33.03' E
LLJ f INC!_UDES S.R. 1633 R/Wf§ AREA= 1.073 AC. - - I UILDI 430.24 P.I.PLLJ � -
z E.I.P Z
140.08 168.38 ado
0 3 N 86.47'39' M F.I.P 17�E0 N.I.P I c_
E.I.P If�f o N.I.P N 86.4 39' W 87.18' • W . . • I H 6
209,65E.LP 65N"IP cZi
N
40 AREA= m
1.f;73 AC. BUILDING o
W
AREA= `"
KENNETH S. N AREA= 3.600 AC. cu
F' D.B. IRELAND f: 1.0 73 A C. n
-.RAVEL— - - 105, .PC. 6'69 o N }. � m +a� INCLUDES S.R. 1630 R/W ) g
16' z �"
PC.. 806
N I
WELL
E.I.P N.86'08,31, V
13.11
N 85'13'02' M 4
�- N •13' N.I.
N.I.P ..
W E.I.P 429.94
+- R/R SPIKE f 8
0.5' EAST OF CENTER
SHARON A. FRAN
D•B. 117, PC. 853 0 SHARON A. FRANCO
& son MICHAEL FNC0
D.B. 177, PG. 244
I I, GRADY L. TUTTEROW, CERTIFY THAT UNDER
MY DIRECTION AND SUPERVISION, THIS MAP
WAS DRAWN FROM AN ACTUAL FIELD SURVEY
MADE BY TUTTEROW SURVEYING COMPANY.
---------------------------------------
�� PROFESSIONAL LAND SURVEYOR L-2527
TUTTEROW SURVEYING COMPANY
PREI-AMINARY 124 SOUTH SALISBURY ST.
MOCKSVILLE, N. C. 27028
(336) 751-5616
PRELIMINARY
PLAT OF SURVEY FOR,
VIOLET ARMS WOR THY, HEIRS
LECEND REVISIma t" = 100' APPREMM BY@ JOSHUA
• E.I.P.= EXISTING IRON PIN G.L.TUTTEROW
JAN-20-2000 �FIL!M- ARMS-VI1
QbP.I.P.= PLACED IRON PLACED
O N.I.P.= NEW IRON PIN (D.B. 48, PG. 265) LYING IN THE FARMINGTON TOWNSHIP
N = R/R SPIKE 100 S) O 100 200 300 DAVIE COUNTY, NORTH CAROLINA
DRAWING MMKRI
SCALE IN FEET TAX MAP REF.: E-7, PARCEL 108 1800-3