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
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/
\
\
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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
,..��
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.
�
•, 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 - Long-term acceptance rate - gaUday/ft2
DCHD OS/99 (Revised)
ii
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