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861 Daniel Rd�sL� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990001638 Billed To: Patricia Peacock Reference Name: Proposed Facility: ResidenCe ATC Number: 2754 Ta x P I N/ E H t: 5736-54-0058 Subdivision Info: Location/Adtlress: Daniels Road-27028 Property Size: see map AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MUST 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 WASTEWAT CO STRUCT IS VALID F R PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: � J Date: �`�� � b r CERTIFICATE OF COMPLETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 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. Septic System Installed By: c�� ���D�y'� " /l U �-5 � (__- Environmental Health Specialist's Signature : /�/ /_� Date: � o�� '�/ DCHD OS/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section `� '' :� , P. O. Boz 848/210 Hospital Street , Mocksville, NC 27028 � (336)751-8760 �?�- �- z i—<+ ,. IMPROVEMENT/OPERATION PERMIT Account #: 990001638 Tax PIN/EH #: 5736-54-0058 Billed To: PatriCia Peacock �� Subdivision Info: Reference Name: � Location/Address: Daniels Road-27028 Proposed Facility: Residence Property Size: see map ATC N��p b�r: 2754 **NOTE** "1'his mprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AL]THORIZATION 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 PERMTT 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 /%i f I #People �� #Bedrooms C� #Baths �,_ Dishwasher: � Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �� C.-' Type Water Supply '���� Design Wastewater Flow (GPD) _S� Site: New� Repair ❑ System Specifications: Tank Size/Ob� GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width,�(� Rock Depth � Linear Ft.��� I1�IPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF G" BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m. to 930 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-87G0.**** �_ , Environmental Health SpecialisYs Signature: � ,� Date: �'-��a a/ C. DCHD OS/99 (Revised) + Gladatone Rd 1,G�wqr Rob�rt Ston�,Profpdono�LarW Swv�yor, 1-3�92. certify to one f--Daniel Rd SR 1121 of tlr foSo�M�q w irdleaf�d UMa. � w �'�; ' 1i � a. That MY plat I�ot a n�rvq�tlqt cnatM a mibdlvrion of land vrlthM tlw ana of a cour�a munkqdity that Iw�ar orClranc�Uwt Nancy Easter �oop � � o � ; � ^ Cabls Ln !-1 b. That thN plat b d a arv�y tfwt b IocatW k�wch portbn ot� ,, •, IJ �b,���apb,y�4����to on ordinonu ,��,s,� SR '182 ttqt rpubta poro�Y o}IorM; i � a TAd Mis pb!f�ot a wrv�r d on aNtlnq parcN or pora�s � of fand; 1 Dan(el Rd Ezt � � a. That tf�Wot r of o�urvy o(aath�r catpory, w+cn w ttr � SR t 136 ncort,DMatlon cf scWnq porcW.c eourt_orwroa wrvq a otMr 1 «�����,��d���: - Daniel Rd e. ihot t}r NAormation ovoibbN to thk�urveyor is rvcn Cwt ��om SR 1 136 � �„aei.u�.aw o e.e«�,k+anw,co en.e..t o+mr v�ot«�«+a� Tax Lot 34.10 oa'Yb a.w pwbwn.concan.e �n(c)cnrw,yn;a) oeo... � Tax Map L-4 ��--�.-- n/f Mark Simpson Cullar O i,l SRto;�'Rd Georqa R. Stone L i ��`�� and wife � — �� ����`3-� �ori Butner Culler ,� J �cinity I�ap � ) DB 177 O PG 84 C �� Not to Scate s : Thia surve subdivides the sub'ect ro ert for the ' � Nor�: Y 1 P P Y � conveyance betwaen immediate fOft11�Y Ond 19 exempt Q ' This prop�rty is aubject to oll sassments, right-of-rays, streets onG oeaeesmenta, if any, aa the eame may appsar of of the DaV18 County Subdivision Ordinance. 3/4" EIP O T recora in the ofike of the Register of Deeds, Clerk of Court. Creek Bank S` e �/I7e ' Town or County Tax Office or which may have been ocquired by �2o preacriptiva uee. This eurvey is subject to any factr that may / S1�J3 _� be discioaed by a /uli and accurate title search, NOT fumiehed s��?g, f S 45°33'14"E 199.99' Total as o? t!�ie eate / t;2" EIR � 100.00� If�S 99.99' This map or drowing and any accompcnying documente are fumished to the person(e) named / 1�2�� EIR � thereon and no alterations or use by othero ia permitted unl�se outhorized by ��� Witness Pipe Stone land Surveying Co. / � �J�B�� Elf� Mop not for rocordation, p Fnd Bent re Line O � S 09°59'13"W P�,�;�io� �:�o.000+ 'er'g�a / �o / 39.06' ` �'se i � Tie Line I declare that;,bn - 3 - '�-' 1���9 ��'�0 `- i , / r._-- Point per Deed Distance , s e N 52a25'SO�W 35.72' we surveyed the ptcape��sh�wrS'=:� e / 235.83' Toiai ? this plat: - Q ` 2�•�'� 1' Hexagon Snapea �- ."" r � � '�� 1 / EIR iron Fnd in Line a�E��" � `�� ` �I � 2' \ _ . / • � `'�, � ,... ,:, : -. � , _�`.�: O O \ ., .: ; ,_,,,•= . .��- �,; _�,_� �. / �"�a!�li.t`ti` � Part of Part of \ Tax Lot 34.01 Tax Lot 34.01 0 9'8 Acres -� ' i; 914 Aues + -' \ Pert of Tox Lot 41.08 � `n ?ax Map L-4 0 �x <"" �.--�- � °' I � n/f Goshen Land Corporation � t� �'' �'� � 1 �, \ / DB 82 O PG 106 � i"'. - Y"o ,�.� � o Z �_. z �o � t w f Tax Lot 34.05 / o _���-` +__ ' � � p Tax Map L-4 � 1 � o n/f Lorry G. Cope \ �, `� p � DB 328 O PG 641 / � 1 '" �' -� o \ 0 0 0 \ / - o � / \ \ / � � Point "A": IRS Placed � Per DB 103 O PG ?24 � Dimensions / �� � t�.32' Chord 100.08' Chord 1 dc 1/2" EIP � � .,� � "`�- - ---- t--'--�- Fnd � � -�� � � � N 41°56'14"W N 49'07'05"W �-��-- � ��° Division of the __-`' 100.38' Arc -- - --"100.14' AfC �N 37•31'3��� 2��--'—��' �' -''- Rodius: 800' IRS �_.��- �� ..j.�� -'- Radius: 80�' �--- - - Darrell L. Peacock ------------- - -------- ___- -'�— t �_ - --- _�-�-_ '�_ __�_-_- �_ (.)C. __ _ __, �� _..______— - _----__—_-_ _ � � — ——. __ _-- -— �� � ' - _ _ _ _ - - +` Patricia D. Peacock 1dc1/2" EIP/Bent PK-Nail Fnd O Approximate P ro e rt LEGEND D a n i e I R o a d Center Line of S.R. 1 182 P y R/W - Riqht-of-Way C�nter Lin� Found �L - Center Une S 31°21'S0"E EIP - Exiatinq Iro� Pipe EP - Edge of Povement �R - ExisUng !ron Rebar Fc - Foc. ot c�rb 5.33' s R 1 13 6 Being a Divis+on of Tax Lot 34.01, Tax Map L-4 P - Point PP - Power Pole CM - Concrote Monument �.P �nt Poie From Point "A" • • Deed Book 103 O Poge 724 tRS - kon Rebar Set 1/2" AIH I.rqn Hole R Rod��e 60' Public R W 20'+ — Pavement P/L - Prop�y Vne C - eno.d oista�,ce � � Area Lot 1: 0.924 Acres +/- by coordinate computation c� - Contro�e�cc.ae p7o - port of Area Lot 2: 0.918 Acres +/- by coordinate computation RCP - R�I�orc�d Conerete Pipe SE - Sight Eoaement C►AP - Corruyatsd Metal Pip� De�d Book CPP - Conugated Pbstic P'� P Pbt Book SCALE TOWNSHIP COUNTI' STATE DATE -F- 100 y�or Flood Boundary CB - Catch Boain Y ° FP - Fe�cs Poat = SO' Jerusalem Davie North Corolina 3-08-20ot -O- p���d Utilitiss S- 5 er u e -X- Fsnce 8oC -�ack o� Curb Fnd - Found Part of Tax Lot 41.08 50 0 50 100 150 n/f Goshan Land Corporation S„�o: Stone Land Surveying Company s�oNO' MT,BL G�orq� Robat Ston�, PLS L-3182 DB 82 O PG 106 MAP N0. A/APPED: " � G-,�• ���e :n,�A �;3�Ei 9?8-a7�:' GRAPHIC SCALE — FEET cRs M��k����,,e �;�; �,ozg s33oi ,..�� .'►• . � •, APPUCATION FOR SITE EVALUATION/iMPROVEM1iFM P�fiM1SIT & AT p � ` Davie County Health Department � Environmenla/ HeaUfi Section P.O. Box 848/210 Hospital St-seet . Mocksnille, NC 27028 (336) 751-8760 � . �,/— v/ i� C� � d M � _._..____�� ��3� ENVIROi��,�3ENTAl HEALTH ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INE'4RMATION Bi3LLETIN for instructions. 1. xame to be sillea � c�,� r`l c- � c� 1�. �� G!T d'r� Mailing Addresa �� � �'d'��.� �l'V (-� � e ����S���Z=P /`10 �-ks � �\l� �,�-, �.� a �sr 2. Name on Permit/ATC if Dif£erent than Contact Peraon 1 �..�' �-� �.; b. ��', C. ' Home Phone � 3 � r� S�"'3 i I I F3usiness Phone � � �'` � J I ` � / � (} X + ' � 5 A- � � �'�-'e-9,�'y�.') �i %!"� ��r Mailing Add=eas City/3tate/ 'p Gti11 w+"v►k 3. Application For: Site Evaluation mprovement Permit/ATC �e{�Both 'J-d' � 5 2 r►�� d k. � �.�. a. sYet� to ser,.��e: [�Yfiouse ❑ Mobile Home ❑ Business 0 Industry ❑ Other s. If Residence: � People r �i Bedrooms � � Bathrooms � I�I Dishwasher [7 Garbage Diaposal LY Wsahing Machine ❑ Basement/Plua�ing IJ Basement/No Plumbing 6. If Business/Induatzy/Other: Specify type N People M Sinks � Commodes ik 3howern � Urinals # Water Coolors IF FOODSERVICE: # Seats Estimated Water Usage (gallone per a�y) �. Type of water supply: ❑ County/City ��Well ❑ Community e. Do you anticipate additions or eapansions of the facility this system is intended to serve? If ycs, what type? ❑ Ycs �No ***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROP�RTY IIVFORMATION REQU�S7'GD BELOW. Either a PLAT or SITE PLAN MUST BESUI3MITT'ED by the clieat with THIS APPLICATION. I'roperty Dimensions: � ^"-"''�`� Tax Office PIN: # �' 3 � � ( — � D -S� Property Address: Road Name �l/�/'L , r�-S c;tyiz�� If in a Su6division provide informalion, as follows: Name: Section: Block: Lot: _� WRITE DIRECTIONS (from b9ocksvillc) to PROPGR7'1': �-7 ��..,�C c��..� �- i� �- �,.,.�. S R � 3 r�- �n �.-�l �� _ . � �f .� ` -�� Sf-r'4- •d'/tc�t' ,� !- �-� o w-b /e �� � )"�' , - -f'D 1-' '�' � �,�(� � l � C� �f �-' ��„ ��� Date Property Flagged: '� v l This is to certify that the information provided is correct to the best of my knotivledge. I uuderstand thAt any permit(s) issued hereaftcr are subject to suspension or revocation, if the site plans or intcnded use chaage, or if the informalion sabmitted in this application is fulsified or changed I, a1so, understand that I am responsible jor a/1 charges iircurred from lhis application. I, hereby, give consent to the Authorized Representative of the Davie County Hcalth Department lo entcr upon a6ove described property located in Davie County and owned by � c�, r re�� �' ���-�r��.�,e, �F c�C,� to conduct all testing procedures as necessary to determine tt�e site suitability. DATE SIGNATURE jr' F�-�...�.. �-. !�'-�-�-�c.�.� THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN (Include all of the following: �aisting and proposed property lines and dimensions, structures, setbacks, and septic locations). �� �. �-e-�C-�-.�r -�-t5--•o Sitc Revisit Ct�arge Date(s): ���X —" Client Notification Date: � Revised DCHD (07/99) EHS• Account No. w � � Invoice No. ��� � , • . . DAVIE COUNTY HEALTH DEPARTMENT ` '', � .. •� , Environmental Health Section " � � � Soil/Site Evaluation APPLICANT INFORMATION Account #: 990001638 Billed To: Patricia Peacock Reference Name: Proposed Facility: Residence Water Supply: Evaluation By: FACTORS Slope % HORIZON I DEPTH Texture group Consistence Structure PROPERTY INFORMATION Tax PINIEH #: 5736-54-0058 Subdivision Info: Location/Address: Daniels Road-27028 Property Size: see map Date Evaluated: �>�—��_ � On-Site Well Community Auger Boring [� Pit HORIZON II DEPTH Texture group Consistence Swcture 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: LONG-TERM ACCEPTANCE RATE: �' 1 2 ,� Public Cut 3 4 5 6 7 EVALUATION BY: OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R- Ridge S-$houlder L- Linear slope FS - Foo[ 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 frm 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 Mineralo�v 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 - 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