341 Bailey Rd . . • , ��-
' • , , ' , � • DAVIE COUNTY HEALTH DEPARTMENT
' ' � ' Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87G0
Account #: 990002739 Tax PIN/EH#: 5880-85-1081
Billed To: Chad Fuller Subdivision Info:
Reference Name: Location/Address: Bailey Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3459
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CON TR CTION IS VALID FOR A PERIOD OF FIVE YEARS.
+ ` ��� i �
Environmental Health Specialist s Signature: Date: ��� ?J�
CERTIFICATE OF COMPLETION
**NOTE** T'he issuance ofthis Certificate ofCompletion shall indicate the system described on ImprovemenUOperation Permit
has been installed in compliance wit icle 11 of G.S.Chapter 130A, Section.1900"Sewage Treatment and
Disposal Systems,"but shall i O WA en as a,guarantee that the system will function satisfactorily for any
given period of time. �p�� �
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Septic System Installed By: `��=h'ti-'�'� `-,-'�/ �
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Environmental Health Specialist's Signature: �'� Date: � �
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DCHD OS/99(Revised)
. . . DAVIE COi1NTY I�EEALTH DEPARTMENT �� 5� � � r�
M , Environmental Health Section �
�. ; • � ', ' P.O.Boz 848/210 Hospital Street
a Mceksville,NC 27028
(33G)751-87C0
IMPROVEMENT/OPERATION PERMIT
Account #: 990002739 Tax PIN/EH #: 5880-85-1081
Billed To: Chad Fuller Subdivision Info:
Reference Name: Location/Address: Bailey Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3459
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People � #Bedrooms� #Baths_�
Dishwasher:� Garbage Disposal:� Washing Machine:�Basement w/Plumbing:�� Basement/No Plumbing: ❑
Commercial Specification: Facility Type r #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply�� Design Wastewater Flow(GPD)� Site: New� Repair❑
System Specifications: Tank Size�d GAL. Pump Tank GAL. Trench Width c� �`Rock Depth /�r,��Linear Ftcf��
� �/D d
Other:
Required Site Modifications/Conditions:
11�1PROVEMENT/OPERATION PERMI ' � EFFL R. RISER(S)IF 6"BELOW
FINISI�ED GRADE. ****NOTICE: Conta resentative ofth�Davie County epartment for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 1:30 p.m. on tHe day of installatio Telephone#is(33G)751-87(0.****
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Environmental Health Specialist's Signature: Date:�����
DCHD OS/99(Revised)
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�. • ► . • ° APPLICATION FOR SITE EVALUATION/IhiPROVEM[NT PERMiT& TC N11�t>>�1�U3t��p�,��r� �
+ Davie County Health Department "�'^--.
� ' •Q N� Environmenta/Hea/th Section �'AY �
� ����`�1 p.o. soX s4s/aso Hospital street _ 9 2�03 ;
� ,� Mocksville, NC 27028 �
(336)751-8760 ''���
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***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQU
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
� �'l-�a� ��-���
1. Name to be Billed �' ' / �'��- Contact Person
Mailing Address �/ / � Home Ph e ��� ���/
City/State/ZIP ������Sl/I//Ci /��� ����ess Y��one ��� 1��
2. Name on Permit/ATC if Different than Above
Mailing Addrass City/State/Zip
3. Application For: Site Evaluation Improvement Permit/ATC
4. Syatem to service: House Mobile Home Business Industry Other
5. �f Residence: # People � # Bedrooms �� # Bathrooms Gf
--r
---.. ,_
�ahwasher Garbaga Disposal% ashing Machine asement/Plumbing Basement/No Pluxnbing
--_._�____----'""_-„_� '�,,�,-,____'___
6. If Businesa/Induatry/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Watar Usage (gallons per day)
7. Type of water supply: County/City Well Community
a. Do you anticipate additions or expansions of the facility tl�is systcm is intended to serve? Yes No
If yes,what type? � �s��f��''�.��i''�. l�l ��'.>Cn/ZCj'L
***IMPORTANT***CLI�NTS NIUST COMPLETE 1'HE REQUlRLD PROPLRTY INFORIVIATION RGQULS'I'GD
BELOW. Eitl�er a PLAT or SITE PLAN MUST BE SUBMITTED by U�e client �vith THIS APPi.ICATION.
Pro rty Dimensions: ������� WRITL DIR�CT[ONS(froni l�locksvillc)to l'ROPGRT�':
�'��o --gs-� ��r��c��x����� �'���d D//l���s
Tax O fice PIN: #
Property Address: Road Name ����et/��� <�►'l��,�/"—'4'�1� �
City/Zip �"��/'/�/�,� � '
i/pr�. CE� �7ad�
If in a Subdivision provide informat�on,as follows:�
Name:
Section: Block: Lot: Date home corners flagged: `� � _
This is to certify tl�at the information provided is correct to the best of my Icnowledge. I widcrstand tliat any permit(s)
issued hereafter are subject to suspension or revocation,if tlie site plans or intended use change,or if the information
submitted in this application is falsified or changed. I,also,understaitd that I nu���espousiGle for all clta�b�es uicurred fi•om
this application. I,hereby,give consent to tl�e Authorized Representative of the Davi C�un,t��'H h gp artment
to enter upon above described property located in Davie County and o�vned by���r�'� � / � �
to conduct all testin procedures as necessary to detcrmine the site suitabi '
DATE � � � � SIGNAT'URE
THIS AREA MAY BE USED FOR DRAVVING YOUR SITE PLAl�t(Include all of ttic followii3b: Existing and proposcd
property lines and dimensions, structures, setbRcks, and septic locatioris).
Site Revisit Charge
Datc(s): .
Ciient NutiGcation Date:
F:HS:
Sign given Account No �� 3��
Revised DCHD(07/99) Invoice No. �b s
f Iron Bent
Edgard E. Vogler I Lance D. Schamback, certify that this plat was draw under my supervision i
from an actual survey made under my supervision (deed description and/or
Deed Book: 53 Page: 421
' Map Book _SEE—, Page _ NOTE—2 That the boundaries not surveyed are clearly
indicated as drawn from information found in Book _N1A Page _N1A_; that
the ratio of precision as calculated is 1: 10,000+ that this plat was prepared j
Found
Flat Bar w in accordance with the Standards of Practice for Land Surveying as amended.
(Tie Llne) o
Nee ,w Witness my original signature, registration number and seal.
691.94 Found a This _ 16_—_day of __ DECEMBER 2002.
File ad
— — — -- �
On Llne
L NCE . S AMBACK, PLS
Found 14
Found /4 (Tie Line) Rebar ° '� LICENSE NUMBER: L-4295
O
Rebar S9000'00'W 523.38 (�e?4/", �o�^ 6��1//IIIIIItgtrt
A
IPS
= ����
Edith Bailey Slagle
Page: 376
Deed Book: 65 Pa g
�Q s
Q
r' L-j4 0
X,:v ,s
y�.��-��.
s
l�h
5
1'215,
/Ps 95 Tote f
3S4 99
/ Found 14
Found 1 1/2" Rebar
P/pe
?3a 46
i
/PS
I
1
William A. Bailey Eta]
Deed Book: 431 page: 453
o�o
'TT
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a
i
�n
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i
O
Road
O
Vogler o
SiteO
8 William A. Bailey Eta]
Deed Book: 431 Page: 453 O
° Bapey Road � Tract 2
15.00 Acres
Tract 1
Mill Peoples Creek
1
Feed Mill
� 15.00 Acres
Road M / LINE TABLE
o LINE LENGTH, BEARING
Vicinity Map Not to Scale ti ti
�� �-�- \_ L 1 51.40 I S86 57'11"W
o L2 53.60 N70'10'00"W
ti
O
:H
� I LEGEND
C(I,4VF_ TABLE R/W = Right—of—way
CURVE LENGTH , MDIUS BEARING CHORD
Cl
78.701.,,'744.76 N85'10'09"W 78.70 I.P.S. _ #4 Rebar Set
C2 338.03 i 2!44.76 N8931'08"W 337.82
--A, = Not to scale
E] = Telephone Pedestal
c-QL) = Utility Pole
= Cable Pedestal
VIM
= Water Meter
Guy Wire
� I
j RCP = Reinforced Concrete Pipe
® = Well
Found/'4
1) This property may be subject to any Easements, Ips Rebar R/►,, IPs Found 14
C2 Rebar
Rights-of-way, and/or Restrictive Covenants. Line) - Cl Found 14
�n� W 229.os Ll
Paved�V -- 50'Public —•� N84.2o'S,2 � Rebar Found/4
' 2) Boundary information based on Deed Book: 431 a t - r 576.5+'2'" y`-"ie"RCP~ � Rebar Q GRAPHIC SCALE
1 ___ -- 248.85
Page: 453 as recorded in the Davie County Register of Deeds. _ Rte, 1a'RCP ~ NB3!"15'43���. `°' zoo 400
234.32 100 0 50 100
L� 15' Drainage Barley Road
3) This survey was prepared for the purpose of showing the proposed Found /4
Rebar Easement 5. �• 1657
division of two 15 acre tracts, for Taylor F. Bailey. Deed Book: 144 15' Drolnoge �1
N�'a, Page: 92 Easement "1
Deed Book: 144 / J IN FEET
15 Page: 98 1 inch 100 ft.
4) No N.C.G.S. or U.S.G.S. Monuments �,�- William A. Bailey =
could be located within 2000 . / Deed Book: l00
Page: 878
5) Area by coordinate method. o
6) #4 rebars set at all corners unless otherwise noted. Albert B. Russell a� Found 114-
J❑B NAME;
Deed Book: 124 Page: 166 Solid Iron
7 Points not labeled found or set are computed points only. aft/ Boundary Survey for
8) Right of way agreement: Deed Book: 144 at Pages: 91, 92, 94, 96, / PATTIRSON '9y
98, 99, 100 and 101. �g T�
for Bale
Found LOCATION! SHADY GROVE TOWNSHIP, DAVIE CO.7NC DRAWN BY, PAF CHECKED BY, JHP
/4 RebarTAX PARCEL NUMBER: A PORTI❑N ❑F F90000004SCALE; 1' = 100'
io Engineering * Surveying * Planning OWNERS
DATE ❑F FIELD SURVEYS DECEMBER 2002
Post Office Box 1387 * Mooresville, NC 2.8115 DATE ❑F MAP; DECEMBER 16, 2002
F
/ound
Found
4 Rebar 704/662-0100 * Fax 704/662-0101
J❑B NUMBER SHEET NUMBER
M02279
' � . '. , . , DAVIE COUNTY HEALTH DEPARTIVIENT
. � � ' Environmental Health Section
� ' ' � ' '' Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990002739 Tax PIN/EH#: 5880-85-1081
Billed To: Chad Fuller Subdivision Info:
Reference Name: Location/Address: Bailey Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: ��'�2 "?1�
Water Supply: On-Site Well �� Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition .L
Slo e%
HORIZON I DEPTH �� �
Texture rou l C
Consistence
Structure
Mineralo
HORIZON II DEPTH '` `y
Texture rou �'j
Consistence
Structure i S' �
Mineralo -
�"
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE �' �
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-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 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-Slightiy 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-gaUday/ft2
DCHD OS/99(Revised)
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