1730 Hwy 158 HEALTH DEPARTMENT RELEASE For Office Use Only
*CDP File Number 121526)-2
a+srA7Z Davie County Health Department
H5-000-00-067
210 Hospital Street County ID Number:
P.O. Box 848
- 4 Evaluated For: HDR/VMC
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID 0 7 / 2 5 / 2 0 1 8
UNTIL:
Applicant: Christopher Coburn Property Owner: Robert McClamrock
Address: 4760 Forest Manor Dr Address: 181 Lowder Lane
City: Winston-Salem City: Mocksville
State0p: NC 27103 StatefZip: NC 27028
Phone#: (336)682-6472 Phone#: (336) 998-0796
Property Location&Site Information
FAddressL_7 E Subdivision: Phase: Lot
lle NC 27028
LE FAMILYTownship:
Directions
#of Bedrooms: #of People: Next property North of 1622 on Hwy 158 on Right.across road from
1697
'Water Supply: PUBLIC
Basement: F Yes❑No Type of Business:
Total sq.Footage: No.Of Employees:
'Proposed Improvement:
Remodeling old building
`Release Conditions
approved for 2 bedroom only
This release in no way expresses or implies that the existing subsurface sewage treatment and dispose
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:- 0 7 2 5 2 0 1 3
Authorized State Agent:
**Site Plan/Drawing attached.** Total Time:(HH:MM)
0 1 Hours 0 0 Minutes
(D Hand Drawinq Olmport Dravvinq
Edit Property Page 1 of 1
North Carolina
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Onsite Smmge
Edit Property Cancel
-Indicates a Required Field
Status ACTIVE DAVIE COUNTY HEALTH DEPARTMENT
File/Parcut Numbers 122512 — Environmental Health Section
PIN iE7-000-o0-t to P.O.Box 848.210 Hospital Street
County Davie Mocksville,NC 2728
336.753.6780
Subdivision or Property? 1PROPERTY
Plat Date I
L
Address t 1576 Baltimore Road
Address 2
City I State/Zip JA nce North Carut.ra 27006 Google Mao By Address.
Township
Subdivision �—
Slack I Let!Section I F—I —
Lot Size 0.46 NIA
Zoning ( —
Setback Front I Back �— I",
Setback Left I Right ftR
Latitude I Longitude F --- Google Map.,
Hwy 158.right on Baltimore Road.Home on right just
before Juney Deaurhamp Rd.
DirecO
No repair permit issued.Per Rusty Miller with Randy Miller
and Son Septic stated cracked lid.You may reach them at
Continents 336284-2826,for any questionsordocuments.
Current Applicant Maul,-, : -'I V¢ta•i.t G Fus:hcr;c
Owner Information
N—ic iMatthem Todd and Victoria G.Hutchens
Address 1 57S ca:'incn;R+
Address 2
C.'y/:,-i.r:c 17.,-
V.,
Zig
..':c Co^acct
Copyright 412012 Custom Data Processing,Inc.All rights reserved.(ncenvosw version 2.1.15 60712013 isd8 0 2 db=kypeodl i
hups://portal.cdpehs.com/NCENVOSW/OSW PROPERTY/EditOSW_PROPERTYRecor... 7/31/2013
Davie County Health Department
";D P836' Environmental Health Section ,
' �` RA►� '1/ P.O. Box 848
210 Hospital Street
O U - Courier# : 09-40-06
' Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(336)-751-8786
ON-SITEW FOR DWELLING
(Check ne) Replacemen' Reconnection
I
Name: 1 ey �� Phone Number 33 Cc tpt� (ay:2 a (Home)
Mailing Address: 71P 10 -Iac'm f'Yla r r 53 q f q 787Y (Work)
Email /o
Detailed Directions To Site:!-f '� 1"6't-,cob
' T iu G ' /J'r�
Y — 42
TVQ b l/ `r Q/1 r� r s
Property Address- / /+ 9�
A0 �.5 .
Please Fill In The Following Information.About The EXISTING Facility:
Name System Installed Under: 1+ i 11 lu"Ai SEW, Type Of Facility:aqY t C t.d "
Date System Installed(Month/Date/Year): A?7015`S Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No If Yes,For How Long? LIT)1L V-10A,
Any.Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: ,t'' t/ �, 7 Q p S'/ry& WM Number Of Bedrooms: J Number of People
Requested By: c`�a J'n/C r06U yyt J Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments: G W oZ -�r O
Environmental Health Specialist Date: 201
*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<fCMoney Order # C27424e Amount:$ 160
/ Date:
Paid By: k) Received By:
Account#: Invoice#:
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L. — 1740 lr��—r �t T— 133
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All data is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the implied
(E
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 causes of action due to or arising out of I'ri rated:J u 116 2013
S the use or inability to use the GIS data provided by this website. ,
IMPROVEMENT PERMIT For Office Use Only
r 'CDP File Number 121526- 1
�� �
County ID Number.
H5.000.00-067
Evaluated For. NEW
Township:
PERMIT VALID UNTIL: 5/21/2018
"NOTE TO INSP DIVISION: Permits cannot be issued with this Improvement Permit.
pplicant: Chris Coburn rAdd7ress:
wner: Robert McClamrock
Addre Ct.
181 Lowder Lane
Clemmons Y Mocksville
State2ip: NC 27012 State2ip: NC 27028
Phone#: (336)766-6857 Phone#: (336)998-0796
Property Location & Site Information
rH
dress/Road #: Subdivision: Phase: Lot:
wy 158 E
ocksville NC 27028 Directions
structure: SINGLE FAMILY Next property North of 1622 on Hwy 158 on Right.
#of Bedrooms: 3 across road from 1697
#of People:
'Water Supply: PUBLIC
System Specifications .
nitial System
*SiteClassification: Ps
Minimum Trench Depth: 2 4 Inches
Saprolite System? OYes ONo Maximum Trench Depth: 3 6
Inches
Design Flow: 3 6 0 Septic Tank: 1 0 0 0
Gallons
Soil Application Rate: 0 . 2 5 1-Piece: OYes ONo
Pump Required: OYes (D No OMay Be Required
*System Classification/Description:
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
`Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Repair System Required:G Yes ONO ONO, but has Available Space
Repair System
`Site Classification: PS Minimum Trench Depth: 2 4 Inches
Soil Application Rate: 0 2 2 5 Maximum Trench Depth: 2 4 Inches
'System Classification/Description:
Pump Required: OYes ONo O Maybe Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 25%REDUCTIO N
Pagel of 3
CDP File•Nurrlber •1'21526- 1 County ID Number. H5-000-00.067
*Site Modifications ❑ Open Fill Sheet
No grading or constriction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate goveming bodies in meeting their requirements.
Site Plan The Improovement Permit shad be wild for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to
scale that shows the existing and proposed property lines with dimensions,the locaton of thefacilrty and appurtenances,the
0 site for the proposed Wastewater system,and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
surveyor,drawn to a scale of one inch equals no more than 60 feet'that Includes:the specific location of the proposed facility
O and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision tots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that Is accompanied by a site plan that Is drawn to scale).
The Department and Local Hearth Departrnent may Impose conditions on the Issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article.This permit Is subject to revocation if the site plan,plat,or Intended
use changes(NCOS 130A335(Q).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,
reporting,and repair(.1938(b)}
Applicant/Legal Reps.Signature Required? OYes ONO
Applicant/Legal Reps. Signature; Date:
*Issued By: Date of Issue: 0 5 2 1 2 0 1 3
Authorized state Agent: OValid without Expiration?
0Create CA.
OHand Drawing Olmport Drawing
**Site PlanlDrawing attached.** Total Time:(F11—IJA t)
0 1 Hours. 0 0 tt1nutes
Page 2 of 3
Activitv Code:
IMPROVEMENT PERMIT 12152fi - 1
-CDP File Number.
County File Number: HS-000-00-067
NC Date: I l
Q inch
Drawing Drawing Type: Improvement Permit Scale: , OBiock
QN/A
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Page
T Page 3 of 3
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC A '
Cos, Davie County Environmental Health Date.
P.O.Box 848/210 Hospital Street t
Metr
ocksville,NC Ree
J (336)753-6780/Fax(336)753-1680 Receivedb .
'
Application For:ZitFv.luationfTmprovement Permit 11 Authorization To Construct(ATC) I Both all
Type of Application: New System Repair to Existing System UExpansion/Modification of Existing System or Facility
IMPORTANTw"THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Rcfer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATIONA / ,p/
Name to be Billed ('�S C 4 / Contact Person inA trS dAyz l
Billing Address &_,, e t Home Phone 336 7 6—0a'$57
City/State/7.1P /!9 Business Phone 33 6 S//y 7Sf7f�•
Name on Permit/ATC ifDi jerent than Above
Mailing Address d6,7 6 W/t City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged 1)�_ 3
NOTE: A survey plat or site plan must accompany this application. Included:X Site Plan I Plat(to scale)
(Permit is va"d t60 months wsit p•n,no expiration with complete plat.) 9q1-,077X
Ov�mer's Name , Ze6t7_ ' Ci d aPhone Number
O%vner's Address A'61 ow er City/State/Zip�i� 70J-5
Property Address MSS 1•ZD�yr 7 City Abekruill&
Lot Sizc !2 awle S Tax PIN# 415'000_,0 0-0 V'
Subdivision Name(if applicable) Section/Lot# p
Direc.
iopslToSite: NL°1CT n i lf/vri a
If the answer to any of the following questions is"yes",supporting documentation mast be attached.
Are there any existing wastewater systems on the site? I'Yes t*o
Does the site contain jurisdictional wetlands? L!Ycs XNo
Are there any casements or right-of-ways on the site? _'Yes JcNo
Is the site subject to approval by another public agency? r?Ycs XNO
WilI wastewater other than domestic sewage be generated? Yes J(No
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms _ #Bathrooms�o _ Garden Tub/Whirlpool_Ycs KNo
Basement: Yes Basement Plumbing: -lyes YNO
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:xConventional I Accepted !_'Innovative 71Altemative I:Other
Water Supply Typc:,'ounty/City Water New Well ❑Existing Well Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?_Yes /No
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 hereby grant right of entry to the Authorized
Representative oft Davie County Health D mcnt to conduct necessary inspections to determine compliance with applicable
laws and rules. ndcrst• that I am able for the proper identification and labeling of property lines and comers and
locatin a- g akar{;the ility location,proposed well location and the location of any other amenities.
�f Site Revisit Charge
Property owner's or owner's legal representative signature
13 Client Notification Date:
Date EHS:
Sign given Yes No Account#
Revised 11/06 Invoice# low
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All date Is provided a Is without warranty or guarantee of any kind either expressed or Implied including but not IlmW to the Implied
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warranties of merchantability or fitness for a particular use.Ali users of Davie Countys GIS website shall hold harmless the County of t
- .I
Gavle,North Carolina,its agents,consultants,cantraetore or employees from any and all claim or causes of action due to or arising out Pn Rt@u:Anr 05, 2013
5 of the use or Inability to use the GIS data provided by this website. P
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DAVIE COUNTY HEALTH DEPARTMENT.'
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990006075 Tax PIN/EH#: H5-000-00-067
Billed To: Chris Coburn i Subdivision Info:
^ Reference Name: Location/Address: Hwy 158-27028
Proposed Facility: Residence Property Size: 15.590 Ac Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 _ 2 3 4 5 6 7
Landscape position
Slope.% ,
HORIZON I DEPTH
Texture group
Consistence
"Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure K S l
Mineralogy
HORIZON III DEPTH
Texture groupC,
Consistence !
Structure ,
Mineralogy
HORIZON IV DEPTH'
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION hf
LONG-TERM ACCEPTANCE RATE 1245 1 , ,
SITE CLASSIFICATION: r EVALUATION BY: Adke&)
LONG-TERM ACCEPTANCE RATE: 1'Z5 `� � OTHER(S)PRESENT:
REMARKS:Of IttyllAA dLA IV ! GG-
°'^ C Ni a�l� LEGEND
ndsc pe Position C1vLytoWjJ 61(3 At 4-1c
R-Ridge S -Shoulder L-Line slope FS-Foot slope -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
NS-Non.tticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP Nonplastic 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 f
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)
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Parcel#: H500000067 Page 1 of 1
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Davie County, NC - Basic Estate Search 01-orni-S
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Parcel#: H500000067 Account#:8302263
Owner Information Tax Codes
OBURN CHRIS JOHN&COBURN SHARON CHRISTINE ADVLTAX-COUNTY T
IMIOCKSVILLE,
730 US HWY 158 FIREADVLTAX-FIRE TAX
NC 27028
Property Information Township
nd(Units/Type): 15.590 AC MOCKSVILLE
ddress: 1730 US HWY 158
Deed Information Local Zonin
ate: 05/2016 Book: 01019 Page: 0230
Plat Book: Page:
Legal Description PIN
16.642AC HWY 158 1 1 5749332338
Property Values
uildin 104,89
BXF: 2,O0
nd• 90,64
CCCC
Market: 197 53
ssessed: 197 53
eferred•
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
00087 0257 04 1972 WD Unqualified Vacant 0
00751 9400 10 2000 FS Unqualified Vacant 257,652
01019 0230 05 2016 QC Unqualified Improved 0
00927 1052 06 2013 WD Qualified Vacant 90,000
View Prggedy Record for this Parcel View Mao for this Parcel View Tax Bill Information
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All Information on this site is prepared for the inventory of real property found within Davie County. All data Is complied from recorded deeds,
plats, and other public records and data. Users of this data are hereby notified that the aforementioned public Information sources should be
consulted for verification of the information. All information contained herein was created for the Davie County's internal use. Davie County,
its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or
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If you have any questions about the data displayed on this website please contact the Davie County Tax Office at(336) 753-6120.
1.5.9
http://maps.daviecountync.gov/itsnet/View.aspx?prid=1492441 6/14/2016