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713 Farmington RdDAVIE COUNTY HEALTH DEPARTMENT 41 f Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account M 990003452 Tax PIN/EH #: 5841-63-2069 Billed To: Marie Black Subdivision Info: Reference Name: Location/Address: 713 Farmington Rd -27028 Proposed Facility: Residence Property Size: 1 acre **NOI�lC* 4ffr ro#Mgnt/Operation Permit DOES NOT authorize the construction of a 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 bw1�41} #People 3 #Bedrooms 3 #Baths Z Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: e . Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type//►► #People #People/Shift #Seats Industrial Waste: 13& Lot Size Type Water Supply ^'Izj Design Wastewater Flow (GPD) --3CC-V Site: New Repair ❑ System Specifications: Tank Size 1000 GAL. Pump Tank GAL. TrenchWidth ZV 2 � Rock Depth �'l Linear Ft. Coto# Other: &W t=-✓a'7ne7 r -L -o vy YAL liC-1 4 i�)I STt2,A 7bo j oiri,-s f Required Site Modifications/Conditions:/ML1I-L dF� is 6 IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this 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 installation. Telephone # is (336)751-8760.**** Coo' i�Faa) UAeE-� i J s l vc�—fZ 3!� 122 • 1k TR&,%eA -Pef VALVE1-10 _— '113 , ) ,.I D � Environmental Health Specialist's Signat Date: ------------ �7 lr-�.J r i •J 1., DCHD 05/99 (Revised) �—TFI &S Account #: 990003452 Billed To: Marie Black Reference Name: ATC Number: 4449 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5841-63-2069 Subdivision Info: Location/Address: 713 Farmington Rd -27028 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 W=e:AS3 IS ALID OR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signa Date: % CERTIFICATE OF COMPLFTT(-)N Pa&'. Lt�1 **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvemen Operation Permit has been installed in compliance with Article I 1 of G.S. Chapter 130A, Section .1900 "Sewage TVtment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the st wil fun ion a sfactorily for any given period of time. ,9 M 0-061 t �e.a5 T 4 � 2H 2 I► "moo �t,* -Mr, r%.:- 4 -3o Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: q ire a { a a ro < x � -� h � k S- d x � "fid .b, � } .' ,,� •`q a rA - L � ° Y 4 � y x f D A JAN 1 0 2005 �rnRpAVtE COA_�...-. )N FOR SITE EVALUATI ON/IAIPROVE&I ENT PERMIT & ATC , 64 Davie County Health Department Envil'onmenta/Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed ff )a2er- Contact Person 7/em' �. 19a Mailing Address '7 % F�2/n iy2, f'oN tJ ''`� Home Phone 334-9982W7 City/State/ZIP Mee-Kst-n,02t Business Phone 919_ 6 Z/ - 3a65 2. Name on Permit/ATC if Different than ly4a li 6/*G/c .Above Mailing Address _ / f � /�4^` 11 2C1 City/State/Zip O c.-kcsvlII � Ive, 3. Application For: Site Evaluation ��`House I y, 13 improvement Permit/ATC Both 4. system to Service: ❑lll wilobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested:)(Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People 3_ # Bedrooms 3 # Bathrooms []Dishwasher❑Garbage Disposal Mashing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks It Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: li Seats Estimated Water Usage (gallons per day) 8. Typo of water supply:County/City [I well ❑ Community 9. Do you anticipate additions or Cxp211Si0I1S of the facility this systein is intended t0 serve? ❑ Yes YN0 If yes, what type? ***IJITPORTANT*** CLIENTS MUSTCOAIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBAIITTED by the client with THIS APPLICATION. Property Dimensions: / WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tax Office PIN:lE l � 560 0000 C;z c/.. C'7' % 2t� m �io0 f� s Ui �1 r G i-&' f $g sg Property Address: Road Namct%h-2//G`Joni I:4�f- City/zip /2Z If in a Subdivision provide information, is follows: Name:' J-CPf- Section: Block: Lot: Date liome corners flagged: ho s This is to certify that the information provided is correct to the best of niy knowledge. I understand that any permits) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the inforination submitted ill Misapplication is falsified or changed. I, also, witterstand that I ani responsible for all charges hiciared from this application. I, hereby, give consent to the Authorized Representative of the Davie County IIeaIth Departnient to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to deterniine the site suitability. DATE SIGNATURE TIIIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). 33* F Sign given N)o ~ Revised DCIJD (05/03 Client Notification Date: EIIS: Account No. 3 / az Invoice No.c� p, v �y o' 4 � c h w � F v v t a •V-tel '"-..__ � ": N (3 . 85A) c, 2069OR ................t w L liv NZ-) '43 APPLICANT INFORMATION Account #: 990003452 Billed To: Marie Black Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5841-63-2069 Subdivision Info: Location/Address: 713 Farmington Rd -27028 Property Size: 1 acre Date Evaluated: { /2� Community, Evaluation By: Auger Boring ✓ Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position L' Slope % ` HORIZON I DEPTH U(� 'r �� •- �=' Texture group CL- (� !- Consistence Structure all 55 < Mineralogy`�- HORIZON 11 DEPTH - 2 L- 1.7 - I LI 1 o ' ' p-0`0 Texture group U_ 01— Consistence f'VS Structure %!C th iA-\ 0— Mineralogy MI uci') t_1t,_ -' LT )c 41.14PHORIZON III DEPTH ZZ. - �" f Lo `'L�l ? ' _ •U �c -- 3 Texture group S C -+S _- ' } S S f' C -a > r Consistence F i 5 ,Sr' - S Structure 4�l< K Mineralogy HORIZON IV DEPTH 3t 4/ or Texture group S4-jf)(4( S. Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION ` v� LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: US EVALUATION BY: E_'��4'qUt-ci4U-I' LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT: v REMARKS: Ai{ 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 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 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 DCHD 05/99 (Revised) ■ ■ ■ ■■■■■■■■■■■uiiiii�r■■■■■■■■■■■■■■■■■■■■■■■�■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MENU■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MEMO MEMNONiiMMAIII iinommonEMMEMEMOMME Eli!■■���l�l��li,�.'ii'I■■■■ ■■■■■■■■■■■■■U■ ■■■■ ■I/■■i�1i1■■it■fit,■■■■■■■■■■■I■■■■■■■■■■■■■■■ ■■■■ ■■teNr:.►���1•ee�eee�eee■e■��eeeeee■e■ee■■N ■■N■ ■■■■■uaimmo■e :■■■►�■■M■■��■■■■M■■■■■■■■■■■■■ ■ ■ a � eai h as b s roNM �Wlrp' powr t 7 `iia Y .m i 0 114, 3a a R i �'ii�"P �� n i ���,""i�� i V� � '^ i i is �`y �• � a��� i� ar� 777, F E�4� tY s ii 4�i"r�i��� �rig' �j":i�i �ta�i�y-;•r i iy�,, i 11 �m 'S VP N V i ,'i7AJ© 41,&` si s as Ih DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION P.O. Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760/Fax: (336)751-8786 January 21, 2005 Marie Black 713 Farmington Road Mocksville, NC 27028 Re: Site Evaluation: 1 Acre of 3.49 Acre Tract Farmington Road Tax PIN: 5841632069 Dear Client(s): As requested, Jeff Beauchamp, Environmental Health Specialist with this office on January 20, 2005 evaluated the above -referenced property at the site(s) designated on the plat/site plan that accompanied your improvement permit application(s). The evaluation was done in accordance with the laws and rules governing wastewater systems in North Carolina General Statute 130A-333 and related statutes and Title 15A, Subchapter 18A, of the North Carolina Administrative Code, Rule .1900 and related rules. Based on the criteria set out in 15A, Subchapter 18A, of the North Carolina Administrative Code, Rules .1940 through .1948, the evaluation indicated that the site is UNSUITABLE for a ground absorption sewage system. Therefore, your request for an improvement permit is DENIED. The site is unsuitable based on the following: Rule .1941 Soil Characteristics. These severe soil or site limitations could cause premature system failure, leading to the discharge of untreated sewage on the ground surface, in surface waters, directly into ground water or inside your structure. The site evaluation included consideration of possible site modifications, and modified, innovative or alternative systems. However, this office has determined that none of the above options will overcome the severe conditions on this site. A possible option might be a system designed to dispose of sewage to another area of suitable soil or off-site to additional property. For the reasons set out above, the property is currently classified UNSUITABLE, and an improvement permit shall not be issued for this site in accordance with Rule .1948(c). However, the site classified as UNSUITABLE may be reclassified as PROVISIONALLY SUITABLE if written documentation is provided that meets the requirements of Rule .1948(d). A copy of this rule is enclosed. You may hire a consultant to assist you if you wish to try to develop a plan under which your site could be reclassified as PROVISIONALLY SUITABLE. You have a right to an informal review of this decision. You may request an informal review by the environmental health supervisor with this office. You may also request an informal review by the N.C. Department of Environmental and Natural Resources regional soil specialist. A request for informal review must be made in writing to the Davie County Health Department, Environmental Health Section. 62 You also have a right to a formal appeal of this decision. To pursue a formal appeal, you must file a petition for a contested case hearing with the Office of Administrative Hearings, 6714 Mail Center, Raleigh, N.C. 27699-6714. To get a copy of a petition form, you may write the Office of Administrative Hearings or call the office at (919) 733-0926 or from the OAH website at www.oah.state.nc.us/form.htm . The petition for a contested case hearing must be filed in accordance with the provision of North Carolina General Statutes 130A-24 and 150-13-23 and all other applicable provisions of Chapter 150B. N.C. General Statute 130A-335 (g) provides that your hearing would be held in the county where your property is located. Please note: If you wish to pursue a formal appeal, you must file the petition form with the Office of Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS LETTER. The date of this letter is January 21, 2005. Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a formal appeal within 30 days will not interfere with any informal review that you might request. Do not wait for the outcome of any informal review if you wish to file a formal appeal. If you file a petition for a contested case hearing with the Office of Administrative Hearings, you are required by law (N.C. General Statute 15013-23) to send a copy of your petition to the North Carolina Department of Environment and Natural Resources. Send the copy to: Office of General Counsel, N.C. Department of Environment and Natural Resources, 1601 Mail Service Center, Raleigh, N.C. 27699-1601. Do NOT send the copy of the petition to Davie County Health Department. Sending a copy of your petition to Davie County Health Department will NOT satisfy the legal requirements in N.C. General Statute 150B-23 that you send a copy to the Office of General Counsel, NCDENR. Please call or write this office if you have any questions or need any additional assistance, as follows: Telephone number: (336) 751-8760 Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 Enclosure(s): Soil -Site Report Rule .1948 Invoice Sincerely, c� Jeff G. Beauchamp, R.S. Environmental Health Specialist IN LAWS AND RULES FOR SEWAGE TREATMENT AND DISPOSAL SYSTEMS 15A NCAC 18A.1900 Rule .1948 .1948 SITE CLASSIFICATION (a) Sites classified as SUITABLE may be utilized for a ground absorption sewage treatment and disposal system consistent with these Rules. A suitable classification generally indicates soil and site conditions favorable for the operation of a ground absorption sewage treatment and disposal system or have slight limitations that are readily overcome by proper design and installation. (b) Sites classified as PROVISIONALLY SUITABLE may be utilized for a ground absorption sewage treatment and disposal system consistent with these Rules but have moderate limitations. Sites classified Provisionally Suitable require some modifications and careful planning, design, and installation in order for a ground absorption sewage treatment and disposal system to function satisfactorily. (c) Sites classified UNSUITABLE have severe limitations for the installation and use of a properly functioning ground absorption sewage treatment and disposal system. An improvement permit shall not be issued for a site which is classified as UNSUITABLE. However, where a site is UNSUITABLE, it may be reclassified PROVISIONALLY SUITABLE if a special investigation indicates that a modified or alternative system can be installed in accordance with Rules .1956 or .1957 or this Section. (d) A site classified as UNSUITABLE may be used for a ground absorption sewage treatment and disposal system specifically identified in Rules .1955, .1956 or .1957 of this Section or a system approved under Rule .1969 if written documentation, including engineering, hydrogeologic, geologic or soil studies, indicates to the local health department that the proposed system can be expected to function satisfactorily. Such sites shall be reclassified as PROVISIONALLY SUITABLE if the local health department determines that the substantiating data indicate that: (1) a ground absorption system can be installed so that the effluent will be non-pathogenic, non-infectious, non-toxic, and non -hazardous; (2) the effluent will not contaminate groundwater or surface water; and (3) the effluent will not be exposed on the ground surface or be discharged to surface waters where it could come in contact with people, animals, or vectors. The State shall review the substantiating data if requested by the local health department. History Note: Authority G.S. 130A -335(e); Eff. July 1 1982 Amended Eff. April 1, 1993; January 1, 1990. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME �V DATE EVALUATED Z-1 Zi PROPOSED FACILITY SUBDIVISION Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit PROPERTY SIZE ROAD NAME r �G�n-�,,, a vu'J Public / Cut FACTORS 1 2 3 4 5 6 7 Landscape position t_ 6. 1 - Slope % 3 2 HORIZON I DEPTH o - Ln ^ �� - I 0-11 0-12 Texture group SA- , G1 _ G CL- GI_ fRr�K Consistence Fr SS SP Fr SSS 5 r-r5S S Structure Mineralogy1C�St HORIZON Il DEPTH 1 l0 ' 32 f l 21- 2- -tul Texture group C t C Consistence QvS%Ifj FagyP L 11 V V , VS-vv- SvStructure Structure 4131t Mineralogy kvt t HORIZON III DEPTH ( X -3LI 161 -3Lj 3 L-LILJ 22 --Z Texture group 01 k St 4212 Consistence S '1 Structure A Ie nr� Mineralogy not ;(ZD �=1c HORIZON IV DEPTH 314-5 1 �1 ' S.�' qq 2 - yo Texture group Se QUQLTZ 5a12 ((-S Consistence ffr P— I`5►9. Structure 6k Mineralogy SOIL WETNESS 53 RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION i FS I PIS os S l VS LONG-TERM ACCEPTANCE RATE 1 0• L 1 0.2 •2 SITE CLASSIFICATION: (J W LONG-TERM ACCEPTANCE RATE: 0.2 REMARKS:�'VAL-17i MIXti�I� I� i#f3 ��CP 4 PMS' LEGEND DCHD (01-90) Landscaue Position EVALUATION BY: �' f iwm al -c OTHER(S) PRESENT: 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 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 SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky SBK - Subangular blocky PL - Platy PR - Prismatic Mineralog 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 Q s s ia- a b �. (3. 4A) a. 131 7,77-7---f JAI £9b too �� _w �.Y..e x >..• � ,'aka:. fig` ssa t £9b too �� _w v i�) Ma a,,' say za MrB2 E 0 tZ' N EnB z (51.80A) Z 7901 i3 W SeB 88.705A E n B 71`5$, s ArA iu,. 1165 1166 Ib�"IN Wl p wing ' , v i�) Ma a,,' say za MrB2 E 0 tZ' N EnB z (51.80A) Z 7901 w•wuyL 1UHT CANDLE 836998 1084 f.�_•....y 05/30/06 11:06am P. 002 BKb01PG4Rr' 002G2i FILED FOR REGISTRATION April 5, 2005 10:12 a.m. DATE TIME AND RECORDED IN BOOK 601 PAGE 491 M. BRENT SHOAF, REGISTER OF DEEMS r AVIE COUNTY, NO, t3Y M Deputy DRAFTED BY: T. DAN WOMBLE f%,,�' /c►: 'i�3 :a:�lrNGhrcJ�i� iUlcc.f�su^. ;r�'>re NORTH CARnt._LNA l DEED OF EASEMENT DAVIE COUNTY } THIS DEED OF EASEMENT, made this the _1-51 day of April, 2005, by and between David Engle and wife, Bridgett Engle and Leslie R Bradley, parties of the first part; and Herbert Thomas Black, party of the second part; THAT WHEREAS, the parties of the first part, in 'consideration of Ten Dollars and other valuable consideration ($10.00 o.v.c.) to them paid by said party of the second part, the receipt of which is hereby acknowledged, have bargained and sold, and by these presents do bargain, sell and convey unto the said party of the second part a non-exclusive, perpetual easement for the purpose of installation and maintenance of a septic system and related drainage lines over and across a tract or parcel of land in the County of Davie, and State of North Carolina, easement being described as follows: FOR DESCRIPTION OF EASEMENT SEE EXHIBIT "A" ATTACHED HERETO. TO HAVE AND TO HOLD the aforesaid non-exclusive easement. for utilities and septic system purposes to the party of the second part and !• s successors and assign in . *ie forever; it being agreed that the easement hereby granted is appurtenant to and runs with the land now owned by party of the second part as described in Deed Book , Page , Davie County Registry. And the said parties of the first part do covenant that they are seized of the premises in fee upon which said easement is granted and have the right to grant said easement; that the same is free of encumbrances and will warranvand defend the title to said easement against the claims of all persons whatsoever, IN TESTIMONY WHEREOF, the said parties of the first part have caused this instrument to be properly executed the day and year first above written. COACHLIGHT CANDLE NORTH CAROLINA FORSYTH COUNTY 336 398 1084 05?30?06 11:06am P. 003 BK b 0 1 PG 4 9 2 4 a Notary Public of said County and State rso hereby certify that David Engle and wife, Bridgett Engle and Leslie R. Bradley personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal this jQj_ day of April, 2005. My comission expires: NO* "YPUBLIC DAVIE COUNTY, STATE OF NORTH CAROLINA The foregoing certificate of Martha S. McBride, Notary Public of Davie County, NC is certified to be correct. This 5th day of April, 2005. M. BRENT SHOAF, REGISTER OF DEEDS Deputy: ;;-�'C—UL OFFICIAL SEAQ Nw DAVIE COUNTY S M E es - DAVID ENO�r OFFICIAL SEAL BRWGE7r ENGLE MARTHA v S.CRII)F1 /7 FFICIAL SEAL LESLIE R. BRADLEY DAVIE COUNTY MARTHA r Kly GOMM.issjOn Expires Mj a Notary Public of said County and State rso hereby certify that David Engle and wife, Bridgett Engle and Leslie R. Bradley personally appeared before me this day and acknowledged the due execution of the foregoing instrument. Witness my hand and official seal this jQj_ day of April, 2005. My comission expires: NO* "YPUBLIC DAVIE COUNTY, STATE OF NORTH CAROLINA The foregoing certificate of Martha S. McBride, Notary Public of Davie County, NC is certified to be correct. This 5th day of April, 2005. M. BRENT SHOAF, REGISTER OF DEEDS Deputy: ;;-�'C—UL --ru-AL'") UANDLE 33699B 10B4 � 05!30!06 11:06am P. 004 BKbO i PG493 EXHIBIT "A" BEGINNING at an iron, said iron being located in the Southeast comer of David Engle, Deed Book 549, Page 668 and the Northeast comer of Bessie S. Smitherman, Deed Book 413, Page 44, Davie County Registry; thence from said point of Beginning along Smitherman's North line North 87 deg. 13' 32" West 651.68 feet to a point; thence North 01 deg. 59' 02" East 140.02 feet to a point; thence North 13' 32" West 80.01 feet to a point; thence North 01 deg. 59' 02" East 350.03 feet to a point; thence South 87 deg. 13' 32" East 100.01 feet to a point; thence South 01 deg. 59' 02" West 470.04 feet to a point; thence South 87 deg. 13' 32" East 633.57 feet to a point; thence South 07 deg. 22' 31" West 20.06 feet to an iron, the point and place of Beginning, and being in accordance with a survey prepared by Donald I Moore, PIS, dated March 7, 2005. NO 'riTI,E SEARCH R.EQUES ED ANT) NONE i`Ei'..FORMED. Davie County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 May 30, 2006 Marie Black 713 Farmington Road Mocksville, NC 27028 Re: 1 Acre Tract/Farmington Road Tax PIN# 5841632069 Dear Client(s): As requested, a representative from this office visited the above site January 20, 2005 and February 18, 2005 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. 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. Improvement Permit System To Serve: 3 :;V- Wastewater Design Flow: System Type: D(; (3. 4A) 131 .Z4:_„