356 Greenhill RdHEALTH DEPARTMENT RELEASE
y arm Davie County Health Department
N d p„rx a. yd
210 Hospital Street
y - P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Robert Timm
Address: 356 Greenhill Road
City: Mocksville
State[Zip: NC 27028
Phone #: (336) 492-2090 ,
For Office Use Only
*CDP File Number 123898-1
13-000-00-056-04
County ID Number:
Evaluated For: HDRANWIC
PERMIT VALID 1 0/ 2 5/ 2 0 1 8
UNTIL:
Property Owner: Robert Timm
Address: 356 Greenhill Road
City: Mocksville
State[Zip: NC 27028
Phone #: (336) 492-2090
r Property Location & Site Information
Address356 Greenhill Road Subdivision: Phase: Lot
Road# Mocksville NC 27028
SINGLE FAMILY Township:
*Structure: Directions
# of Bedrooms: 3 # of People: Hwy 64 West, Turn Left on Greenhill Rd. at comer of McDalister Road
and Greenhill Rd. on right.
*Water Supply: PUBLIC
Basement: R Yes a No
'Proposed Improvement:
Garage
Type of Business:
Total sq. Footage: No. Of Employees:
It is the responsibility of the owner to maintain a 5' minimum setback between the wastewater system and any partof the structure
foundation, including porches, decks, and any other appurtenances. If you are unsure as to the exact location of the septic system, please
have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the
proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this
property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed.
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? OYes ONo
Applicant/Legal Reps. Signature: *Date:
*Issued By: 2244 - Daywalt, Andrew /� *Date of Issue: 1 0 / 2 5 / 2 0 1 3
�, Authorized State Agent: ��qa�
**Site Plan/Drawing attached.* (Total Time:(HH:MM)
_ _ n 1 Hniirc o n iN inijrP.0
-A
NVt Davie County Health Department �3
1836 Environmental Health Section I
Im+D P.O. Box 848 /
210 Hospital Street ClG®
Courier # : 09-40-06
U Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 751- 8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name: Phone Number Z� I (Home)
Mailing Address: % j�`-� �,�� t�y1 (Work)
"Z -10Z*` Email
Detailed Directions To Site: 14f.'I" (aLL 74 y u
Property Address:
Please Fill In The Following Information.About The EXISTING Facility:
�• 5( t�A_Cl
Name System Installed Under: �- Type Of Facility:
Date System Installed (Month/Date/Year): to (— LU7 Number Of Bedrooms: 3 Number Of People:
Is The Facility Currently Vacant? Yes If Yes, For How Long?
Any Known Problems? YesN,..g> If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: 3Z Number Of Bedrooms: .__--""**Number of People
Requested By: Date Requested: 16
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash
Paid By:
Money Order #.
114
Received By:
Account #: AM Invoice #:
Date: //1 //,—
27,J, --
K7
XALLIS rzR R7
M
M
A17"IN
All data is provided as Is without warranty or guarantee of any kind either expressed or Implied including but not limited to the Implied
'W— f. warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the Country of U V;
Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of
the use or inability to use the GIS data provided by this website. Printed:Oct 16, 2013
�3, 00 0 - 00 - 05-(15, -C)q,
r
r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990003935
Billed To: Lana McCarthy
Reference Name:
Proposed Facility: Residence
ATC Number: 4535
4446
Tax PIN/EH #: 5728-254,249-
Subdivision
728-25.424&Subdivision Info:
Location/Address: Green Hill Road -27028
Property Size:
As stated in 15A NCAC 18AA969(5)
accepted sv,tQms may also be used
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 S reatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW CIOKISA�LI/QOR A I AOFFE YEARS.
Environmental Health Specialist's Signatur ate: O&
CERTIFICATE OF COMPLETION
**NOTE** The 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.
1
rW
4
Septic System Installed By: >�J G�
Environmental Health Specialist's Signature: Date: V� ;
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
,r P. O. Box 848/210 Hospital Street fd,
Mocksville, NC 27028 LI -0 ��ii
(336)751-8760 ��� `- -0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003935 Tax PIN/EH #: 5728-25-4249
Billed To: Lana McCarthy Subdivision Info:
Reference Name: Location/Address: Green Hill Road -27028
Proposed Facility: Residence Property Size:
ATC Number: 4535
**NOTE** This Improvement/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 Hou -SF— #People _;0- #Bedrooms #Baths 3
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 3. �� Type Water Supply�`�T`1�Design Wastewater Flow (GPD) Site: New Repair ❑
System Specifications: Tank Size 1CX:DGAL. Pump Tank GAL. Trench Width 3(.-� Rock Depth IZ' Linear Ft.lk�
•� AN nN.tod In 1.5A NCAC 18A.1969(5)
Other: �1�T�1St7Ci .�s`S, accen�oc; sv ij=)ms :nay also be used
ired Site Modifications/Conditions:
Kot ---P -'s' F-jp-- , V: -)-P 11:5 C4 -P
MPROVEMENT/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
i" tem 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.****
110' "1 1\/i i
VEnvironmental Health Specialist's Signae:
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEME A--�
Davie County Health Department MAR 3 1 2006
Environmental Health Section
P.O. Box 848/210 Hospital Street ENYIRONNI?ITAI HEAUFi
Mocksville, NC 27028 DAVIECOUNIY
(336)751-8760/ Fax 336)751-8786
Application For: Site Evaluation/Improvement Permit .eAuthorization To Construct(ATC) ❑ Both
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be BilledA04.,AyContact Person
Billing Address 0 Home Phone
City/State/ZIP I.?ffOL)72 Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/Sta
PROPERTY INFORMATION
NOTE: A survey plat or site plan must accompany this application. &tT-d#X3 600000 5-6 0
(Permit is valid for 60 months with site plan, no expirat•on with complete plat.
Street Address{( )SS 10)A el jl� /I LZ� ity Tax PIN# �7;���� yg
Subdivision Name /(//,4 Se_ctiin/Lot# Lot Size
Directions To Site:T ie .C/ /i/i.,f A,
�. /�/arls/i�Z-
Date House/Facility Corners Flagged .� �/ v �o — e/Melt dirPCf /,qactAss IVM /U,u
If the answer to any of the following questions is "yes", supporting documentation must be attached. -62d .-F/ZZ ys ��Y. —<44,
Are there any existing wastewater systems on the site? Dyes XNo
Does the site contain jurisdictional wetlands? Dyes XNo
Are there any easements or right-of-ways on the site? ❑ Yes � NoS�GO-
Is the site subject to approval by another public agency? ❑Yes KNo
Will wastewater other than domestic sewage be generated? ❑Yes;QNo Q�
IF RESIDENCE FILL OUT THE BOX BELOW 4 1
# People # Bedrooms :— # Bathrooms �o' _ Garden Tub/Whirlpool [,Yes ❑No
Basement: ❑Yes XNo Basement Plumbing: ❑Yes ;A�No
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business 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: Yconventional ❑Accepted ❑ Innovative ❑ Alternative ❑ Other
Water Supply Type: X County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes XNo
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 permit(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 charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to det. mine co lianc w' applicable laws and rules on the above described property located in
Davie County and owned by 1� ��,_
Date
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Sign given Eyes ❑No Account #
Revised 2/06���`� Il �5 7Zq Invoice # ����
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003935 Tax PIN/EH #: 5728-25-4249
Billed To: Lana McCarthy Subdivision Info:
Reference Name:. Location/Address: Green Hill Road-270?8
Proposed Facility: Residence Property Size: Date Evaluated:
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring Pit
Public
Cut
FACTORS
1
2
3 4 5 6 7
Landscape position
Slope %
Z
'�
HORIZON I DEPTH
Texture group
C-
4--A—
LConsistence
Consistence
F, s
Structure
S,Sk
C.k
- k
MineralogyS
=�
HORIZON II DEPTH
Texture group
C<
Consistence
Structure
A$
SF -k
Mineralogy
HORIZON III DEPTH
Texturerou
S
Consistence
S
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
V
LONG-TERM ACCEPTANCE RATE
O.3
SITE CLASSIFICATION: V5
o 2;
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY:
OTHER(S) PRESENT:
t I")�. 34Qf, Z
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
0,
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
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
lyotes
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 05105 (Revised)
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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
April 13, 2006
Lana McCarthy
PO Box 629
Granite Quarry, NC 28072
Re: 7.19 Acre Tract/Greenhill Road
Tax PIN# 5728254249
Dear Client(s):
As requested, a representative from this office visited the above site April 13, 2006 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:
Wastewater Design Flow: �C_-) UPZ�,
System Type: Con-v-ennttiio�nal ❑Accepted ❑Innovative
System Location:
❑Alternative ❑Other
Valid: Years ❑No Expiration
Site Modifications/Permit Conditions: I 00C_7 C -IN, TA_,►314
ps-i.p.letter 2/06
I he certify that I am the owner of the property shown
and described hereon, which located in the County of Davis
that I hereby adopt this plan of subdivision with my free consent,
established minimum building setback lines and dedicate all streets,
alleys, walks, parks and other sites and easement to public or
private use as noted. Fultherrnors, I hereby dedicate of sanitary
s
sewand water Jinea to the County of Davie.
•�_ /. — 7 L : DATE
rn
LD
c�
a.
C
D]
0
NO PROVAL REQUIRED BY TK
9XVIE COUNTY PLANNING DIRECTOR
Itis. weiuefMW tlr�il � �� t
eaoW : JEM C HANES
.eh rereset m R.H.araed aawlkl.-fahwwd
by web low r pren,NpatW ,wnwNr cord th.le witerle .d
D(CEPf o=rn0 Mh Is.1d..I—
rhedwtlw d Ofta-kollm and Per slrlRaUelw,
1M wNa- :swt - lie or sdo dePr4nwe.
e1PORTANr NOTICE: THIS CERTIFICATE DOES NOT
CONSnME A PERWr OR APPROVAL OF r4DMDLRL
La15 W SND SUIDWRON FOR MOILA11011 OF
4 Grady L Tutterow, certify that this plat was drown
under my supervision from an actual survey mode
underm'[ supsrWn dee
slod description recorded in
Book 15D ; Page etc.) (other);that the
boundaries not surveyed are chary Indicated as drawn
from Information found in PL Book =, Page
R/R SPIKE
IN RD.
that the ratio of precision is calculated as 1: +20.000
Gf�'_ ^''.
that this plat was prepared in accordance with G.S. •
47-30 osamended. Witness my original signature,
registration number and seal this day of
- "'• /�„ =.
D., 006-
_
Su
A�
(Seal or Stamp) Regielrotton Number
" • ' •�
95.51
�
'
THIS IS AN EXEMPT FAMILY SUBDiNSION
u,„ e..bA•,bb,I
r r
S.n,.vlr Mr fr — na,Ae ...card. Firth —l-
4 L Crcdy L T.To;. III= Lord Survgar, Number L-2527
v �1
..,Ry to one r mond the folbwkW Mdkwted by an X:
_a. That this M e plot da curvy Mat mdse o subdlwwrl of
b
lord within on area ofa oouny r aslnldDdlb Vat has on
ordllanea oatngabt- po-1. of Ww;
_b. That Mb plot b =toy cony that b boated in surd a
portion of o colrAir or municipality that Ie unrepukded m to an
Th.this is that r.gulol- parab d lard;
That
_a. Tplot le at a wrvy d an exletkp poral or
pomle d bred;
�LIL Thal Mle pkat le of a sung of another category. such as the
N_
ncarnbklatlon of e d.0 o sort—ordrsd survey, or
other exception to the Men ofa wlbdM.Ion:
_.. That the bfommfbn ava0able to uae surveyr le sueh
Mat 1 ora unable to • a dot --nation to the beet of ry
d len in
Dy
prwf-w o - • contained a. t rough d. above.
iPLs W
Survs Registration Number
JESSE C. HANES
D.B. 200, PG. 237
ZONED R-20 & RA
RENEW OFFICER'S CERTIFICATE
I, 11.1—.A IrVEYfuAt II , Ravi" officer of Davis County,
Z�EW
at She mop or plot to which this certlficcff n
meet* all statutory requirements for recording.
FFICER
McALLISTER RD. IlSg'
S.R. 1148 l,aol
R/R SPIKE S B9'26'08' E
IN
RD. O 49B, y32
CONTROL
CORNER
.�� TRACT 1
AT:
i INLCUDES S.R. 1115 & S.j 1148 /11
- ZONED R-20
n
d�
TRACT 2
AREA= 3.846 AC.
I I I D'RONNC
i5 8
�1
z
JENNIFER H. STREET
EX
LARRY STREET I IRON
D.B. 545, PG. 885 1
ZONED RA 1
. I
1
I
1
I
1
I
I
1
I
I
I
I
INLCUDES S.R. 1115 R/W
ZONED R-20 & RA
WADE H. DYSON JR.
D.B. 200, PG. 580
ZONED RA & R-20
Fled for registration at _Lo'clocke—u.
54 1{e v 37&h2005 and recorded in
Plat Book �, Pogo ✓ � o .
FFM f- i polo LL Ma SNDAP — DME C. Regwtor d D -de
by
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COMROL
CORNER
R/R SPIKE
IN RD.
W
:o
— N V
W ` =
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33.93
s oz•w'13•�
NEW
IRON
R/R SPIKE
IN RD.
25
S 02.50'13' E�
6&79
hi,
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S 03.25'12' E
rV tt
95.51
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v
r r
5.
S 05;2.
v �1
92.32 L�
b
S OB•28.46' E\
48.83 11
20.
EXISTING
IRON
N_
o � f ��Zqe
Hh'Y
6q
McALLISTER �RD
NO SCALE
VICINITY MAP
--S�uedNNbnWiWO d iNd Dob Cowry. TI Oft od is *Y :.:A.
fwnR/ eldMMm orW
b far ow -ehw11 p,rae•. d IoW emenP frNy mereen
wtllM tlIe tNN dpr- M e,rw IeM ihr bb/Web Md -!
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an,
b ow hAww•VI for tlw- I*N, opp�wolr
Ing M r.RIiW er Deb b eaoe-r Wfan arr/
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1 A.ar - • - _' II,e1�N Mein �„rwew
.ee Ail !. e�.r.rl Nr sire
1, i A N Ore e a t 7Ei L4 e„d
}, JESSE C. HANES _N1_[A_—ley? P„e
Nemo D•�oo��ee-M�y►
S Neer- RelwbrrNp Laf/_ end
4. Let/ . PIN
Nw,r RweualeAP
e. Name R•laaea•I14 L4-
1) 2 TRACTS TOTAL OF 7.7554 AC.
2) TRACT 1 HAS BEEN EVALUATED
AT THIS TIME FOR A PRIVATE SEPTIC SYSTEM
BEFORE A BUILDING PERMIT CAN BE ISSUED
FOR TRACT 2 TRACT AN EVALUATION WILL
HAVE TO BE PREFORMED FOR A SEPTIC SYSTEM
3) THIS PROPERTY IS NOT LOCATED WITHIN
A FLOOD ZONED AREA
4) NO NCGS MONUMENT LOCATED WITHIN 2000 FT
5 MINIMUM SET' -BACKS:
FRONT- 30 FT
SIDE- 15 FT
REAR- 30 FT
6) THIS PROPERTY IS LOCATED WITHIN A WS III
& WS N WATERSHED
PLAT MAP:
JESSE C. HANES
OWNER ------------------ DEVELOPER
JESSE C. HANES
427 GREENHILL RD.
MOCKSVILLE, N.C. 27028
(336) 492-7539
MOCKSVILLE TOWNSHIP
DAVIE COUNTY, NORTH CAROLINA
DATE: AUGUST -15-2006
SURVEYED BY:
TUTTEROW SURVEYING COMPANY
107 NORTH SALISBURY STREET
MOCKSNLLE, NC 27028
(336) 751-5616
1* - 100'
100 50 0 100 200 300
SCALE IN FEET
FILE NAME COORD NAME: DRAWING NUMBER:
HANES-JC HANE -CAR -72 20906-3