340 Cedar Creek RdDAVIE COUNTY HEALTH DEPARTMENT
`' Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(33G)751-87G0
Account #: 989900093
Billed To: Shelton Construction Services
Reference Name:
Proposed Facility: Residence
ATC Number: 4548
Tax PIN/EH #: 5842-02-6004
Subdivision Info:
Location/Address: Cedar Creek Road-27028
Property Size: 1.2 acres
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). This 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 WAST O -R TIO S V OR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatu : Date: � 2�1
CERTIFICATE OF COMPLETION
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**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
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.
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Environmental Health Specialist's
DCHD OS/99 (Revised)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)75]-87(0
IMPROVEMENT/OPERATION PERMIT
Account #: 989900093 Tax PIN/EH #: 5842-02-6004
Billed To: Shelton Construction Services Subdivision Info:
Reference Name: Location/Address: Cedar Creek Road-27028
Proposed Facility: Residence Property Size: 1.2 acres
ATC Number: 4548
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An AUTHORIZATION 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 �W� #People �_ #Bedrooms � #Baths 2
Dishwasher: ❑ Garbage Disposal: � Washing Machine: ❑ Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ��2 �-1 '� Type Water Supply �.�i'(�`�Design Wastewater Flow (GPD) ��� Site: New �Repair ❑
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System Specifications: Tank Size ���GAL. Pump Tank GAL. Trench Width 3�' Rock Depth � Linear Ft. �O�
Other: ���� �o F�E�iJLT10� ����N�,. 3 �s1��Buyic� �'�
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Required Site Modifications/Conditions: K�� � c�� (���t� : �'�L=�� l(�� � i'�.G� (� j•�^
I1�IPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF C" BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
stem between 8:30 a.m,.to 9:30 a.m. or 1:00 .m. to 1:30 .m. on the da of installation. Tele hone # is 33C 751-87G0.****
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DCHD OS/99 (Revised)
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Application For: ❑ Site Evaluatio:
ITE EVALUATION/IMPROVEMENT PERMIT & ATC
avie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (33�751-8786
Pernut ❑ Authorization To Construct(ATC)
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***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
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Name to be Billed _ s ��. I � .._. C . _ � '�-^ .. .. -�; o _ Contact Person � . � S� � � �--. —
Billing Address _12 5---7 v S }.1=,,,. ,� (oy� �[,J Home Phone 3�f-,�'-- Z� n �.
City/State/ZIP �f ti� �( ��•, � �� . C, 2'� o`Z X Business Phone 3 y�-- -� � e
Name on Permit�'ATC if�Diffef�ent than Above
Mailing Address
PROPERTY INFORMATION
City/State/Zip
NOTE: A survey'plat or site plan must accompany this application.
(Pernut is valid for 60 months with site pl �, n� xpiration with complete plat.
Street Address _ 3`i l� G ��. ,. G �.. . � City /��%. ��„ :!��- Tax PIN# S X`�2- OZ' � e� oo �
Subdivision Name Section/Lot# Lot Size /. Z ,4` ,- ��
Directions To Site: L -`l � f-- ,C� . _: .-�-. _ i2 .� L �.1-1- � — � ..�-i: �2: -1, � �./ ��.: l� ,
2�}' o �� ..��� C.� � �.fC. l�-i /�� �,!�'1: /c_ a ��� � 4. f'
Date House/Facility Corners �Flagged � 2 d�
If the answer to any of the following questions is "yes", supporting documentation �m be attached.
Are there any existing wastewater systems on the site? ❑Yes 63�0
Does the site contain jurisdictional wetlands? ❑Yes �
Are there any easements or right-of-ways on the site? ❑Yes �.P3�
Is the site subject to approval by another public agency? �Yes �
Will,wastewater othe� than domestic sewage be generated? ❑Yes �
IF RESIDENCE FILL OUT THE BOX BELOW
# People � # Bedrooms � # Bathrooms Z Garden Tub/Whirlpool �s ❑No
Basement: ❑Yes C�o' Basement Plumbing: ❑Yes ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness 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: �ntional ❑ Accepted ❑ Innovative ❑Alternative ❑ Other
Water Supply Type: ounty/City Water ❑ New Well �Existing Well ❑ Communiry Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �o �
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 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 understand that I am responsible for all clzarges incurred
fi-om this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Depariment to
conduct necessary inspections to deternune compliance with applicable laws and rules on the above described property located in
Davie County and owned by �c .-�- ,. C� � �. ,....� ; ..,.�.
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Property owner's or owner's legal epresentative signature
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Sign given ❑Yes ❑No
Revised 2/06
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account # � Q Q�3
Invoice # __s}_-�C�
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- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil / Site Evaluation
APPLICANT INFORMATION
Account #: 989900093
Biiled To: Shelton Construction Services
Reference Name:
Proposed Facility: Residence Property Size:
PROPERTY INFORMATION
Tax PIN/EH #: 5842-02-6004
Subdivision Info:
Location/Address: Cedar Creek Road-270 8
1.2 acres Date Evaluated: (���I c`��
Water Supply: On-Site Well Community
Evaluation By: Auger Boring � Pit
FACTORS " 1 2 3
I DEPTH
Consistence
Structure
HORIZON II DEPTH
Consistence
Structure
HORIZON III DEPTH
Texture group
Consistence
- Structure
IV DEPTH
Texture
Structure
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
� . LONG-TERM ACCEPTANC
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I SITE CLASSIFICATION: � EVALUATION BY:_ Lfi� �+ C�i,1��
LONG-TERM ACCEPTANCE RATE: ��� � OTHER(S) PRESENT:
REMARKS: /CJr�%��� �C� ��'77G �'`��0�35� � � � TT�� 6,� r.,��P.S
LEGEND
j,andscape 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
T.�t�u�
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
ON ISTF.N .
�'I41S�
VFR - Very friable FR - Friable FI - Firm VFI - Very �rm EFI - Extremely firm
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NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic
S.�[11ci.ur�
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 � .
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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/OS (Revised)
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REVIEIN OFFICER�S CERTIFICATE
' { 'fi; I hereby cartify that I am the owner of the properiy ahown Fled for rogistration at o'clock M. �
� "I and described hereon, which located in tha County of Davie �
l ' that I he�oby adopt this pinn of subdivisio�i with my free consent, I, , Review off�cer of Davie County, !
� established minimum building sotback lines and deoicate ail atreets, cartify thot the map or plat to which this certification 2006 and recorded in a �
� t I •� � Piley�, waiks, parks and other nites and e�ement, �o publtc or is affixed meets all statutory requirements for recordii�g. � � �� SITE
rivate u3o as notod. Furthermore, i hereb dedicate all sanitary � I
! i � sewer and watr.r IincDATE the County of Davie Piat Book _, page � �z 4
����i � � � -
� _ � �� �
� + __ R�/IEW OFFIGEk DATE F���9 t� S paid. IA. BRCM' SHOhF – DAVIE Co. Reqister of Deeds = �
�: P � OWNER s �
�
r� � , by 4�
� DEPUTY–ASStSTANT
� �'`� OWNER
� � N� � PUDCfMG RIDGE RC. �
, � � � ' �
!
�
� ,'��� , o � JERRY F. 0.�'.��N�1.IN.F;' � d
1��. � D.B. 508, 1�G. �a'3 '
���}k;` VI CINI�'�' MA P �
�ri��� � � , Z�INE'D ,t�—.� ���.��.��I.N�R Y .��A��
r
� NEW 112pN �
�N Lrtit ti
32�51 ""=�-. I{we) heroby underotand that thie plat ta opproveci aa exempt from thn �
����'�./���1 Y.L-1�� Lyl,L'1� . , TQTAL= � Subdtvf�lon Ordinance of Davie County. Thfs is a famtly aubdivfston ond �
� 3�`"5Z ie Tor the exclueMe u oee of conv
a 86'0�'-,';• , P rP eying land among famiy me�mhere 4
� w(thln the thlyd doqree of Ilnaal klnship. Thesa lots/tracta ehal! no`
3�'�.OG be uaed for the purpoee of eaM or buildtng develo ent. eithnr now or E
"'�– Ni_lN i� the future, except for those family mem6er-�. ditional approvo;s
IRON may be requlrod by Davie County or ite auecessor aqency befone any �
� . aubaequent saie or buildinq development moy xcur.
.
r
� Owners Date i
if
P � � ' 1151[tbllLp�Il4�4s fho� mv lineal familv m��y� }
� � � Wh0 wlll bn CO�yey9(j Lha newlv GmAtAd }ami(y IOtp �fe; �
t, hA�eby certlly that tho Davle County Health Depa►tment � j
ho3 rwol�oted tl�s aubdiviaion � �• Lot� , anC
� nn•titled : JERh"Y F. CrXENDINE �' � � _ ' Name Relationihip
��Nh ^erpect to criterio and conditionn e�atabliahgd �. Lot� , ond t
k�y mtat� low ar,oromulg�ted theMunder ond the �� � WN a m e R d o ti o n s hi p �
r,.a�m}� i s; f o u n d �o c o m p l y w i t h s u c h c r i t e r f A a n c l �y � 3. Lot�¢ , and p
� conditiom� EXCE"T an act t�uth in fluch eroluation. ��'^f � �: � N a m� •
R�lattonshfp f
For dotnt!a of tlils evaluatton ond far lirriltotions, � �'�. �' tn 4.
� avo the �vritton rnport on file at noid dopottmenG r���`i � Q` , Lot� , and ;
� Name Relationahip
i tINl�ORTMIT NOT1i:E: THIS CERTFlCATE DOES NOT `'� i. '�- 5. Lot� '
{! CONSTi''UfE A PERMIT �f2 MFROVf�I pF IN�MIpUAL [�.+ �� �' Name RelaUonahip � �
SEM�fJ;E� E�ACILff1I�5DMStON FOR INSTALLATION OF ��� '�y �. ���.,A_ 1.2 ��� f�C
t,� ,
, �,"� ".f INCLUOES S.R. 1434 R/V� '� �
m.�o
. ,� a�TE DAVIE CGUN'N HEALTH O�FICFR �1� • , ' .M.D. � �� '
��'" � � _ � _ �� . .. - �N.,�,�'V,� _. � _
..
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. � :�_..._,. _ ___ _. _ _ �._ _ _ _.. . �f� !
RY �, r
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, . f _ __ �� . ; �, W D.B. 5a8, pC. 33 �
� i � ___. � 1�:� �20NE� �
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�� ����,50 � NCTE5: �
s
� "�-w 'Ro�`� 1. TOTAL LOTS= 1 �
� ��N un�E , �
x
"`3`�'{�� 2. TOTAL AREA= 1.213 AC. �
N 86•04•30'i�'"""' , �
� T�TA�` :►53.50 �"'--�--- 3. NO N.C.G.S. MONUMENT WtTHIN 2000� ?
w i
( a 4. THIS PROPERT`f AND ALL ADJOINING PROFERTY ZONED R—A �
� � �� r�c w �
�ac>rv _ �
_ . _. . _ _ _
..� _ �
o �.,., , J�;1R'R�' 1, ' i
QX.�NT.�"N.:; �
Z U.B. 508 � ,
' p�'• �'3 PLAT MAP: �
� � . Z4N.�D R_�q ' �
!' �E.1�.R Y �'. �X�1�.�.�101.;� �
! P/F: t�!,1 i � � �
� �N kC. �^'-- –�.�, ___�._�_.__�___—___� '
OWNER G�VELO�F�R ;
CON7KUI_ � � �� .
( c���E? � I . JERRY F. OXENDINE `i
� N 86•Oa�30 y 340 CEDAR CRE:EK RD. f
� f c71E� ---�,_..�,� MOCKSVILLE, N.C. 27A28 3
� �_�f � a
� ��rf�n,,_._. " __ — — __ -- _ (336) 998-7161 '
- ► � "' � � �roNrr.,c ' - - -- - i
� roR^l[�.,` � — — — .V,. �
� `='= � I FARMINGTON TOWNSHIP i
' °r 1 DAVIE COUNTY, NORTF�I CAROLI�IA �
� � �01�'AI�D L. .�I�ATHIS � �
�•�• 6'73 P'G, 444 � DAT�: Nov-s-2p06 �
� �
� FA}�111.Y EXGEf'T SUBDMSION
� � TAX MAP REF.: D-5, P/0 �k8 +
Surv��XQLGl2LC1fL:911on for Subdivi lon – D'�Cl4ScQuntv. N�rth C.._�n11iIIt1 G o��+D �D---� 's
� I, Gr�(I�j/ L. Tl1t�A�pMI, Registered l,.and Sunreyor, Number L-2:i27 � ��'�`�r�'A��� �. �1ATH�, –
certN'y to one or more of the following an indicated by an :{: � � $U V
�.�^ R EY�D BY: ;
_...,_a. Th�xt thiA ls a plat ot n aurvHy that cr�otea a aubdiviston of ' �73� 1��', /�,4,�;' TUTTER,OW SURVEY.ING COMP:ti,NY i
� land within an orea ot a caunty or municipallty that haf� a�i , ' 2 pNE� �' 107 NORTH SAUSBURY STREET ;
ord(runcn thot �ulotae parceie of land; I, Grady L. 7utterow, cer!ii`y that this piat was drawn ' �
.. �b. That thio p;ot �� of a survey thac �e �ocoted �n aucn o under my superviaion from an octuol surv�y made MOCKSVILLE, NC 27028 �
Pori:ian of a eounty ar municip�ality that ia unre5iulatad oa I:o an under my 9UpCNi9iOf1 (dded descri��tion recorded in ! (336) 751-5616
ordinanc:n that.r9gulatea porcela of land; �
_._c. Th<�t thie plot is of o survay oi an exlating parcel ar E�ook ; Poge , etc.) (other);that the
pr,rc�la Af land; boundories not sunreyed ore clFariy indicated os drown 1„ i �o � �
s ._X„_d. Thnt thla piat Is of a aurvey of another eatogory, such a: tho from informalion found in P�. E3ook �, Poc�e • , �
� recombf�at:lon of existin9 parcele, a court–ardered survey, or tnat the rotio of prFcision is a�lculnted as 1:�20.00�; �Q��v��'¢���]�',�/�r]�] /'� � �T �/��`� `� 1 S � 3 0 �� 9 C
. � othr.r exce:ption to the definition of o aubrJivi�ion; t h o t t h i 9 p l a t w a s p r e p a r e d i n o c c o r d ana� wi t h G S. �J l t:�.I L 1 d,.L'� .(�;( _ ____� `
^,o. Th<�t thrs tnformatlon available to thiffi su r l� such y t
� 9•7-30 os omende�d. �tness my originol signature, �� e
thal: I om unabl�� to make o datermination to the best. of n,y – t
^ � pro t'esa iorn�f a bi lity aa to proviaiona contained in o. through o. obove, reyistration number and seol thi9 day of SCALE I N �EET
A.D., ?.006
� Siqn<iture ____, Suiveyor X== UN,vIAR.KE(� POINT OF PROPERiY � ' �
FILff NAME: COORD NAME: D�AW N; NU�.19EP.: �
Surv�yor Regi�tration .N��mbar {Seal' or Stamp} Reyistrotion Number � OX–CEDR1 OxENDINE-67 O��-3
. �,.,.��,,.�...� ��.. �,_ �
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Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
Improvement Permit ;;
Shelton Construction
1257 US HWY 64W
Mocksville, NC 27028
Re: 1.2 Acre Tract / Cedar Creek Road
Tax PIN: 5842026004
Dear Client(s):
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.
System To Serve: 3��'-S Wastewater Design Flow(GPD): �o� Valid: ❑5 Years �10 Expiration
System Type: ❑Conventional �IAccepted ❑Innovative ❑Alternative ❑Other
Site Modifications/Permit Conditions:
Plan
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i.p.letter 7/06
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