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279 Childrens Home RdDavie County, NC Tax Parcel Report I gjodk, Tuesday, September 27, 2016 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the Davie County, NC implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or 141 causes of action due to or arising out of the use or inability to use the GIS data provided by this website. WARNING: THIS IS NOT A SURVEY cr) Parcel Number: T- Township: Clarksville NCPIN Number. 5813874066 Municipality: Account Number: 40333150 Census Tract: 37059-801 Listed Owner 1: LORD ROBERT W Voting Precinct: CLARKSVILLE Mailing Address 1: 279 CHILDRENS HOME ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE ry DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag. District: a Legal Description: 2.00 AC CHILDRENS HOME RD 4066 COURTNEY x 1.85 Elementary School Zone: WILLIAM R DAVIE Deed Date: o'r-- 280 (C) A: 27 z Deed Book I Page: 002010743 J4 Z MnB2,MdC Plat Book: Flood Zone: x Plat Page: Watershed Overlay: Building Value: 115 Outbuilding & Extra 94 Freatures Value: All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the Davie County, NC implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or 141 causes of action due to or arising out of the use or inability to use the GIS data provided by this website. WARNING: THIS IS NOT A SURVEY Parcel Number: B30000003101 Township: Clarksville NCPIN Number. 5813874066 Municipality: Account Number: 40333150 Census Tract: 37059-801 Listed Owner 1: LORD ROBERT W Voting Precinct: CLARKSVILLE Mailing Address 1: 279 CHILDRENS HOME ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag. District: No Legal Description: 2.00 AC CHILDRENS HOME RD Fire Response District: COURTNEY Assessed Acreage: 1.85 Elementary School Zone: WILLIAM R DAVIE Deed Date: 4/1998 Middle School Zone: NORTH DAVIE Deed Book I Page: 002010743 Soil Types: MnB2,MdC Plat Book: Flood Zone: x Plat Page: Watershed Overlay: Building Value: 49920.00 Outbuilding & Extra 0.00 Freatures Value: Land Value: 16000.00 Total Market Value: 65920.00 Total Assessed Value: 65920.00 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the Davie County, NC implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or 141 causes of action due to or arising out of the use or inability to use the GIS data provided by this website. f.*..i. tt Ct'� d A ' �xIZAToN rio: . DAVIE COUNTY HEALTH .DEPARTMENT Environmental HealthSection PROPERTY INFORMATION ermrtfets P.O.. Box 848. ame_.:-t Mocksville, NC 27028 Subdivision Name: ' Phone #: 704-634-8760, Directions to ProPert y e- /,,�',f Section: Lot: AUTHORIZATION FOR WASTEWATER Office PIN: #, CONSTRUCTION Tax PIN# —� Jame: *.*NOTE** This Authorization for Wastewater System Construction'MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form7Authorization 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) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH tfECIALIST DATE ISSUED .K7.� R�� "/Y Y b�4 ��r.p W:.O � fi4$a4 �-'e'! .y yip' +""R" ��•1..� :- F t � _��' , � ,��/ .r-i.'.,t � - y �,rlr' DAVIE COUNTY HEALTH DEPARTMENTL -126 }� -��"--�,�► � C f IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Mal Directions to property: +�/r• �,�1 r Subdivision Name: Section Lot: IMPROVEMENT IMPROVEMENT PERMIT Tax Office PIN:#�°'�r'�'. Ez f I( Rod Name:eyliiL :!� .r* **NOTE** This Improvement:Permit DOES,NOT'authorize the construction or installation of a septic tank system or any wastewater system An'., AUTHORIZATION FORVWASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a bu g pemut. (In compliance with Article 1 Yof G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) . r T ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR TIS INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH "PECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 1-y # BATHS -1 # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT - # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY 141'/` 1 DESIGN WASTEWATER FLOW (GPD) -�4 NEW SITE—Z,, REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE / e GAL. PUMP TANK - GAL. TRENCH WIDTlk-� ROCK DEPTH LINEAR FT. ;�90 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 �° O 4� �bt e� SYSTEM INSTALLED BY: tv ,91g -4J JI017 )' 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 05/96 (Revised) APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE Davie County Health Department �' a Environmental Health Section • P.O. Box 848 9 Mocksville, NC 27028 (704) 634-8760 . ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed &Z.P kr- 6J. Lan Contact Person Orals.*T' �CST17� . �FZB�r2 Mailing Address f 6,� :�-4 Home Phone 3�� -74 Q - 7 , City/State/Zip "� t�llw J %lp )J (- al 6 2.3 Business Phone A_ 2. Name on Permit/ATC if Different than Above Mailing Address . 2 ,A4- 150 City/State/Zip ",'s"Y 1 A_ MCC, 3. Application For: [ ] Site Evaluation Improvement Permit & ATC [ ] Both 4. System to Serve: [ ] House N Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People� # Bedrooms a # Bathrooms :2, Dishwasher [ ] Garbage Disposal V] 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 ?Z&m Y Koo W • Ft &uRe_ LJeJJ- 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes VC], No If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***'ffffT' OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions:b§1 A 5Z4—L WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # 1� - _[ '�_ - �1,T/�% y"p �� CA) CA&yapza Property Address: Road lame /'-AJnR,-jyrs me- ?Aau eb,u Cdr, Lygd J M& &A'tl 'Ts City/Zip Y):bak5yi0&2, ntc 2.jd2Cg' wQ>Zri Re,Alw�� If in Subdivision provide information, as follows: J Name: A!Zl - Section: Lot #• i 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 Y11 A to conduct all testing DATE3 - 2 �_ SIGNATURE I 111M 7 - Revised DCHD (06-96) THIS AREA MAY BEU§Eb FOR DRAWING YOUR SITE PLAN: necessary. to determine the site suitability. !k 1• :.�:1� ^Cf �;�: �t�.7 A�ns ' i SNL/MW - .. tv^f">+s•.i '' '. dn, -.:+- _ �n+y�7. ,?:�:�.,d-+t.?,s�r.. r�... •: . . •- - , � ,�s ,� iAf. ^{''ri"'1r•-.-:�y. '�.Y�y?r �.J.St if',�^;��7�t'i_is f•ctt� •. _ .. .r - _. :{_�Likt� •••(• I: ,�..iySAP11�� too j� i'' ".'-+S� •,'fit' r Z t*S 1r r ,� 'x 4t.� 3'K.''3.♦tr { N SK .3 AV . tAAA 1, �Z.jf 4low! .1l.S'1 + i. 4 {• y.. 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S• t l 1 ,l .�. 1^ "-.. f f t, a '}S S - f+i 4 S .4 ' •'�f Y�-• i '' K�t .i yw4 a - r ¢ r• «t r s 1 ! �< �•. , fir. P r ss i l Yx 1 - -�5;- } Wiry ��:%•`'�ri=�' ,�.ir.!-' .. APPLICATION FOR SITE EVALUATIONAMPROVE - G Davie County Health Departure Environmental Health Section �171'P.O. Box 848 Mocksville NC 27028 (704) 634-8760 I ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed e�Q O M e— A C40 2-&- Contact Person Mart'o_%Acp Mailing Address lP• i� ' (nx (n Home Phone 3 6 2 '7 City/State/Zip Q��LKy I�� !� C . o��nS S Business Phone 14103- 2 3Q 1• F—XT t 3Z. 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC 4. System to Serve: [ ] House Vmobile Home [ ] Business [ ] Industry [ ] Other [Both 5. If Residence: # People-_ # Bedrooms 3 # Bathrooms :2 [ ] 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 Estimate7V` ter Usage (gallons per day) 7. Type of water supply: [ ] County/City [ell [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [►/l'*No If yes, what type? _ EI 1 t1ER A PL f OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT **4W -V0& OF THE PROPERTY MUST BE v vT l v1 (CL ti • l SUBMITTED WITH THIS APPLICATION. Property Dimensions: 7 $ .K 2 WRITE DIRECTIONS (from/ Mocksville) TO PROPERTY: Tax Office PIN: # g 3 - - Q�p� ; O I K. To �-+ Ot/. Property Address: Road i ame 114 -00-4�s 9-c,,NW �� I�� L h Q,, 1.10. aVk ck-k LG�/�Q11 t city/Zip Ty If in Subdivision provide information, as follows: Name: ; Section: This is 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 �/ I k � / YI / / // • �/ _ to conduct all testing procedures as necessary to determine the site suitability. Revised DCHD (06-96) THIS AREA MAY 13E USED FOR DRAWING YOUR SITE PLAN: ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By Mailing Address Home Phone Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation Septic Tank Installation Permit 4. System to Serve: ❑ House Z( Mobile Home r ❑ Business ❑ Industry ❑ Other 5. If house, mobile home: Subdivision No. of People _ No. of Bedrooms No. of Bathrooms _ Dwelling Dimensions 6. If business, industry, place of public assembly, other: Specify type ❑ Place of Public Assembly ❑ Unknown Section Lot # ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: ❑ Public )(Private 8. Property DimensionAo )(!bs x .flag Y Lk Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? ❑ No ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: O"GA,.U. &f Tax Office PIN #- Road Name C&A&9�'g )L�v)�.& Pox // (if available) City k– This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. DATE SIGNATURE CONSENT FOR SITE EVALUATION TQ BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. I OWN the property. 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: . I hereby give consgnt Jo the authorized representative the Davie County Health Department to enter upon above described property located in D ie County and owned by S ��M `P INS-�$&!LL L— to conduct all testing procedures as necessary to det rmine said site's suitability for a ground absorption sewage treatment and disposal system. 1.?�� e DATE _ ✓) SIGNATURE •_ M V ��, it � � �0 ��1'.. h;, �• � i mom ;�.1�• 31�:.To�'QI�ti°:f'��i�y7��w�''q` t � .. .' • ... i .. �3��,'9"'i 'y�4,y , �� d} >{.,,�-�f. Vii'` his♦1. ,:, 'Ei(� .. - •. " NE • � 4,t�,.rt�� .}3 F`• ft .,� �� e+�.ar�t�,t�yv �ay�, .�3 ;,' �- •• �„ i� ,;} . - • r . w ;-R;;!�!. tu• ,{ 2 1 d +a Y ^ ! x -.Co A C d, jk 4 1h r r" .f GENTLE • 6� pt \�' 115.9 .+��'QEy 3/4" VRON PIPE" iJp`� f r F,\ED i. 78� 14 49, J 1.2��•�'ru. �, Yt I/2' kE9kR ;; Sn 01 b t;. O ^''c."r-a '+� ..T P hF'-4n1 t!';`, 0.P•, r'. c A TOLERANCES .. 1 � W < - • - c i�a _ f j'+7 i"y\r Y . ,T 4r�. -� . d ,` - �1Dit1 NO1E� FRS, . DAIS �Y w rr W.f w m4 wif 42 PT A3 r— J _ r v $?♦X LL��_ � t .e*uy - `y id j_B�•- �♦,� �ELC.� Cc .K V • cc n7. n t, ey .. t,+ ..: ,$a+.. �;i"�'.+'r.r I. �l gTTA' 1i._ at cci�:-„amu; cre c6oTaa t 2 frm bi �is =.,.�. "'r t c • Wi y� r kN(iLtlkR i X51.^•:� i , 1i�`.Mn`,sa' i fi ./' <: "may ,•��...}� �,..-� e �% ! `� t; �t' �1�:/ 'r {7�'R . ■ � i � .��J."i 4 _ . s,:.^(1Ti►�i�Y _� W .E. AI F - Y. SURYEi .F JUN.�.r-IU�S CLARK,SV DAVIE C( DFAWN By CW9 TAk,Gfs� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT • Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY l SUBDIVISION Water Supply: Evaluation By: On -Site Well ✓ Community, Auger Boring (/ Pit DATE EVALUATED :;2—IJ PROPERTY SIZE ROAD NAME Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position 4— Slo e % Slope HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group - Consistence Structure / S Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: dS LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) 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 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 Davie County .�Lealth Department and Home Health Agency Environmental Heafth Section P.O. BOX 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKSVILLE. N.C. 27028 PHONE: (704) 634-8760 February 18, 1598 Diego Mendoza P. 0. Box 1786 Yadkinville, PJC 27055 Re: Site Evaluation Children's Home Road/Site E Tax PIN: #5813-87-4066 Dear Client(s): As requested, a representative from this office visited the aforementioned site on February 1:, 1959. Based upon the information provided on the application for a site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of a modified, oversized on—site sewage disposal system. If you have any questions, please feel free to contact this office. RH/wd Enclosure(s) cc: Zoning Office Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Section f -bo APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE �! Davie County Heal h e rtment Q iroec ' • �n JAN 2 41992 ! �1 y � Mocksville d o � / opo t� ****IMPORTANT**** THIS APPLICATION CANNOT BE P CESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed [ �C17 l "lrL' >OZr'� Contact Person Q V1 Mailing Address nix t i � 6 Home Phone City/State/Zip 141 WV L I k N e • 2705S Business Phone!! 3 3 7_l.{ �p3 "Z 3�, [. �?cT CS7 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC 4. System to Serve: [ ] House [A/Mobile Home [ ] Business [ ] Industry [ ] Other Both 5. If Residence: # 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 X Well [ J Community i5 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***� OF THE PROPERTY MUST BE V 1 fZG 1 Ni A /-{ 4CLL- SUBMITTED WITH THIS APPLICATION. Property Dimensions: *7 e ix, tt -2-q —:W RITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # 5 8 l3 - % - 46 Gfo Property Address: Road lame Gk t UA `f P- W6 4 Q MQ Rd ; � �j L 6-V) City/ziprg 7 OAS' C 'l l,� c- Paw\ If in Subdivision provide information, as follows: M y- e, 1 Name: Section: 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 ' ntative of the Davie County Health Department to enter upon above described property located in Davie County and owned by I ato conduct ll testing procedures as necessary to determine the site suitability. DATE -1 - 2,3 "GT SIGNATURE � / �'f 4,�C� Revised DCHD (06-96) THIS A -6A MAY BE USED Fol? DRAWINC7 YOUR SITE PLAN: 2 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section ' P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By S/ IA Mailing Address __ _- Home Phone Business Phone 2. Name on Permit if Different than Above 3. Application for: ❑ General Evaluation ❑ Septic Tank Installation Permit 4. System to Serve: ❑ House 2( Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # No. of People No. of Bedrooms No. of Bathrooms Dwelling Dimensions 6. if business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Sinks _ No. of Urinals No. of Lavatories No. of Water Coolers. No. of Showers Water Usage Figures, 7. Type of water supply: ❑ Public )(Private 8. Property Dimensions [�a% Y 42A XkSewage Disposal Contractoi 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? If yes, what type? ❑ Basement/Plumbing ❑ Basement/No Plumbing ❑ Washing Machine ❑ Dishwasher ❑ Garbage Disposal ❑ Yes ❑ No ❑ Community I *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: Tax Office PIN Road Name Box ir; (if available) Cit:yy"l�7�\ This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges Incurred from this application. DATE SIGNATURE CONSENT FOR ME EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. i 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consenttJo the authorized representative th Davie County Health Department to enter upon above described property located In D ie County and owned by S N I A % . k I& LL,L. to conduct all testing procedures as necessary to det rmi a said site's suitability for a ground absorption sewage treatment and disposal system.. OiD TE Q ab a J ^ A _ r SIGNATURE DCHD (1193) �ix + !,�,w, t7•� k• r r r:'; .•r,• .. r'•r. t. 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'+v�+r �'f�`,t i -het*ai`�.k/�+trt_ i7 a t MWF.a V.1 •�i:f;h Tx N G > a + T ; ; • : ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME 4 ;x -k z)& O. ADDRESS PROPOSED FACIILTY DATE EVALUATED PROPERTY SIZE 1 C LOCATION OF SITE''/ Water Supply: On -Site Well (/ Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe Z HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture group Consistence Structure /C 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 ACCEPTANCE RATE SITE CLASSIFICATION: 6 ? LONG-TERM ACCEPTANCE RATE: Is REMARKS: DCHD(01-901 EVALUATED BY: Hale 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 SILL -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 3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky SBK-Subangular blocky PL -Platy PR -Prismatic Mineralo 1:1. 2:1. 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BOX 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634.8760 February 18, 1998 Sixto Mendoza P. 0. Pox 1786 Yadkinville, NC 27055 Re: Site Evaluation Children's Home Road/Site 1 Tax PIN: #5813-87-4066 Dear Mr. Mendoza: As requested through your application, Robert P. Hall, Jr., R.S., Environmental Health Specialist(s) with this office, visited the aforementioned site on February 13, 1998. The purpose of said evaluation(s) was to determine the soil/site suitability for the installation of an on—site sewage system. The result(s) of the evaluation(s), a copy of which is attached, indicate that the site is unsuitable for the installation of an on—site sewage system for the following reason(s):. Rule .1940 (d & e) — Topography and Landscape position .1942 (a) — Soil Wetness Conditions Due to the limitation(s) on your site, this office is not aware of any modifications or alternative measures that can be implemented at the present time to upgrade the classification from "unsuitable" to "provisionally suitable." Your application for an Improvement permit must, therefore, be denied. You have the right to an informal review of this decision by the Environmental Health Director of this office and also by the regional staff of the Department of Environment, Health, and Natural Resources. You should contact this office to arrange for this further review. You may also wish to obtain the services of a private consultant to collect site—specific data and submit such data and a system design to this office for technical review. A site may be reclassified to provisionally suitable provided written documentation, including engineering, hydrogeologic, geologic or soil studies indicates to this office that a proposed on—site sewage system or a proposed alternative system can reasonably be expected to function satisfactorily. The substantiating data from these studies must indicate that: F:age• 2 .Sixto Mendoza February 18, 1998 A. The effluent (wastewater) will receive adequate treatment; B. The effluent (wastewater) will not contaminate any ground water or surface water; and C. The effluent (wastewater) will not be exposed on the ground surface or be discharged to surface waters where it could come into contact with people, animals or vectors. Finally, you have the right to a formal appeal of this decision if you file a petition for a contested case hearing with the Office of Administrative Hearings, P. 0. Drawer 27447, Raleigh, N.C. 27611-7447. A copy of a petition form can be provided to you upon request. The petition must be received by the Office of Administrative Hearings within thirty (30) days of the date of this notice. The hearing may be held in Davie County. If you file a petition for a hearing, you must send a copy of the petition to Mr. Richard Whisnant, DEHNR, Office of General Council, P. O. Box 27687, Raleigh, N.C. 27611-7687. Please call or write this office if you have any questions or need any additional assistance. Telephone number: 704/634-8760 Address: Davie County Health Department Environmental Health Section p. O. Box 848 Mocksville, N.C. 270728 Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd Enclosure(s): Soil–Site Report Billing Statement �C zu�rN� 4-Ffice—