4395 Hwy 158 HEALTH DEPARTMENT RELEASE For office Use only
*CDP File Number 122703-1
Davie County Health Department
E7-000-00-069
210 Hospital Street County ID Number.
P.O. Box 848 ?S- /� t�
�'`�-� ` Evaluated For. HDR/WWC
Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 8 / 1 2 / 2 0 1 8
UNTIL
Applicant: Brian Coffey Property Owner. Wayne Webb
Address: 164 Charleston Ridge Dr Address:
City: Mocksville City:
State/Zip: NC 27028 State)Zip:
Phone#: (336)480-5757 Phone#:
Property Location&Site Information
ddress4395 Hwy 158 Subdivision: Phase: Lot
Road# Mocksville NC 27028
Township:
BUSINESS
`Structure: Directions
#of Bedrooms: #of People: Hwy 158,on left across from Snook's BBQ
'Water Supply: PUBLIC
Basement: n Yes n No .Type of Business:
Total sq.Footage: No.Of Employees:
'Proposed Improvement:
Batting Center
'Release conditions
septic tank and lines are under existing parking lot. crossing system could cause damage so cross at your own risk.
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? QYes )No
ApplicantAegal Reps.Signature* *Date: j
*Issued By: 2244-Daywalt,Andrew *Date of Issue: 0 8 1 2 2 0 1 3
Authorized State Agent:
**Site P Ian/Drawing attached.** Total Time:(HH:MM)
0 1 Hours 0 0 Minutes
Hand Drawing Olmport Drawing
,1
Davie County Health Department
111�)his j� Environmental Health Section •.
P.O. Box 848 1
d 210 Hospital Streeto�
Q U Courier# : 09-40-06
Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(336)-751-8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Nam Phone Number �SU����� (Home)
Mailing Address: (Work)
/1� ��C�ylll�i �/ O7iZO Email ��o-F- u�3(� qg�� • C6w�
Detailed Directions To Site: 1 ��'15 ate ff05-S &M
Property Address: -W 4clA l( l
I
Please FM In The FollowingInformation.About The EXISTING Facility: SiNe�
Name System Installed Under: V r/V61�'1{� ��1 Type Of Facility:
Date System Installed(Month/Date/Year): �"G"! Number Of Bedrooms: /J Number Of People:zz
/ Tr/tel
Is The Facility Currently Vacant? Yes If Yes,For How Long?
Any.Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Inform ion bout The NEW Facility: /
Type Of Facility-* /Al Number Of Bedrooms:-Number pf People `/6
Requested By: Date Requested:
(Signa
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 (6hec Money Order # ZO/7 Amount:$ Date:
Paid By: Received By: p I fit/
Account#: Invoice
/22 d3
i
.:
if
•�N4 Y t �1
r-.
r t �
., p
r'` f
• �� � t T
Je
F
�.:'.is�iiQ:innd.�71� e.il F�,4F 1'^�J - •Y _
���✓) Cp F/�y aP�%
/1v �fi6 oo
r
Printed:Aug 05, 2013
All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied
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 the use or
inability to use the GIS data provided by this website.
`-
•-\ >Y7
AUTI�$ION NO: Q 5 7 7DAVIE COUNTY HEALTH DEPARTMENT 41-7e. p i) „
=" Environmental Health Section PROPERTY INFORMATION
Permrte''s "' ' \ (�j1;Q� M C, P.O.Box 848
Name. 2 s� \ Mocksville,NC 27028 Subdivision Name:
1
it Phone#:704-634-8760
Directions to property: i Section: Lot:
AUTHORIZATION FOR �{D
.'S WASTEWATER Tax Office PIN:#5?
SYSTEM CONSTRUCTION
3"bn67' L6-9� Road Name: 158
**NOTE**This Authoi'i�atWn for Wastewater System Construction MUST BE ISSUED by the.Davie County Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S:Ghapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID,FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED *p.
i. `/v�y�•1I.
- .Y�»� -t � ,Ja:S F^.���-`i, r�i •-fl r,l.,i-�"yr.
^= .-. ,. DAVIE COUNTY HEALTH DEPARTMENT
:' `; • IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permit .. .
t r .
Subdivision Name:
Directions to
property: s: '.=�. ,c. Section: Lot:
( `. .IMPROVEMENT r.
ryc�• ^r •,t ' PERMIT Tax Office PIN:#:-,
Road Name: zip:Wl
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation 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)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: AGILITY TYPE$ #PEOPLE 50' #PEOPLEISHIFf #SEATS IDUSTRIAL WASTE Yes No
LOT SIZE TYPE WATER SUPPLY•) DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE/660 GAL PUMP TANK GAL. TRENCH WIDTH ' ROCK DEPTH J�L LINEAR FT.Do ,
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT t5 F
I
f
CT A REPRESENTATIVE OF THE DAVIE.COUNTY HPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
ETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M:ON THE DAY I%STALLATION.TELEPHONE#IS(704)634-8760.
a
OPERATION PERMIT ii iGL�C
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: /Y/� DATE: s
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96(Revised).
• ' APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC
` Davie County Health Department �, 2 a 2
Environmental Health Section D 15 L,
I' P.O. Box 848
�i ,
Mocksville NC 27028 ' 2 6 1996
47 5' � (704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed{fie d l a nd rneehQ nt'C tq I , .VNC , Contact Personfln
Mailing Address,i'3 S f i nebAbo k SCALY-51 Rd , Home Phone `i'n
F
City/State/Zip I t 1 OC. $U /w2. ,/U -C , oZ 70 K' Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [Site Evaluation [`Improvement Permit&ATC [ ]Both
4. System to Serve: [ ]House [ ]Mobile Home [0-dusiness [ ]Industry [ ] Other
5. If Residence: #People #Bedrooms #Bathrooms [ ]Dishwasher[ ]Garbage Disposal
[ ]Washing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Business/Other:Specify type lyse d' %PAZ'Wdilfiople -5 #Sinks #Commodes �;L
#Showers #Urinals #Water Coolers 1
If Foodservice:#Seats Estimated Water Usage(gallons per day) /00 A A Si
7. Type of water supply: [county/City [ ]Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[`]Yes [441No
If yes,what type?
PROPERTY INFORMATION REQUIRED:***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
2� X l'15'
Property Dimensions: ��� X 1°1 q� X � �9• � �WRITE DIRECTIONS(from Mocksville)TO PROPERTY:
Tax Office PIN: #S84 1 - c�-Q87 5 8 s s 14�d
Property Address: Road Name 141., S 6 11 pM
City/Zip n ; �ell�Clrlt�rv�SCJ `�1d0.C�
If in Subdivision provide information,as follows: Best de AA61 EzYo-)
Name:
Section: Lot#: ;
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation,if the site plans or intended use change,or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative
of the Davie County Health Department to enter upon above described property located in Davie County and owned
by iWA ftNec! iS jA� I&C. to conduct all testing procedures as necessary to determine the site suitability.
DATE �_ SIGNATURE
Revised DCHD(06-96)
l
OD
o �
1�6p1 J
0
0
1�9�1
a S
J
n N
OD
s CU
N 1�g6� 120
to
m
�N
J
40
(605)
- O
+ CO
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
DATE EVALUATED
NAME ,
ADDRESS PROPERTY SIZE 1117G�
PROPOSED FACIILTY
LOCATION OF SITE
Water Supply: On-Site Well _ Community Public
Evaluation By: Auger Boring L/ Pit Cut
FACTORS 1 2 3 4
Landscape position .4—
Sloe R
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence i
Structure
Mineralogy V
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 5
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: , EVALUATED BY:
LONG-TERM ACCEPTANCE RATE: / OTHER(S) PRESENT:
REMARKS:
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 ;lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Vc.-y 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
.3C-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mi neralo¢y
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(01-901
iiiiiiiiiiii■�i=rE'iiisiiiiiiiiiiiiiiiiiiiiiiiiii■iii'iiiiii'�i=i■'=i"=iiiiiiiiiiiiiiiiii
■■■■■■■■■■■■.■■■■■■.■■■■.E■e■■■EE■■E.M■u■■■■■■■■NNe='■ ■.■ ■■ _. ■EN ■_■■■■■M■■■■sE■
■■.■■■■■.■■■■■■■■■■■■■■.■.■■■■■■.■■..■■ ■.■■■■■■..n=■=■�■._■ MMIN
■■■■■■■■■■■■■■.■■■■■■■u■■.Et■ u■■■■ ■■■E■M.En .■■ ■■■ ■ ■ ■■ ■■■ ■■■■.■.■
■.■■.■■■■■■■■.■.■■■■■■■■■■■■.u�i.nu■=■ ■..■..�■■.■ ■■■■uE■■■■_■■.■■■■c
�iiiiiiiiisiii=i■'iiiiiii■iiiiiii'iiii�i'.ii■ni■''iiiiiiiiiii '_" mosso mommoiiiiiii
■.■■■■■■■■■■■■_■■■■NEe■■■■a■nE■aE■■t■■n■..E= _■ _� �i■ ■■■■■■■■■N■■■■■
■■■e■■■■n■■nEE■■■■■■■■u■■.■ M■. ■ ■■n ■■ N■. ■■■■■■ ■■■■■
iiiiiiiiii■�■iuiiiiuiiAii'ieSEE'i=' ' _ s"mommom'
■.■■■.■ME.E■■■■■u■■n■■.■ ■■M■■■=■■■ ■ ■ ■ ■■■■■■■■■
■.■■■■.■■■■■■■Eu■■■■■■ ■■ = E■■EMENE■ ■n ..■■■.■■■
■■.■■■■■■■■■■■■.■■■■■■■■ nommommon
IN=:■■■■■ U■■ ■ ■ ■■ ■■■■MENS■
■.■■■■■■■■■■M■■u■■■■S.■Cn■■E�■EE�MEM ■ ■■■■■■■■.■■■
■■Mn■.■■■M■NE■■■■■■■■■■■■sMN■ ■■■E■■■■n ■� E■■■■■■■■■■■■
■■■■■■■u■■E■■■M■M■■■■nN■ ■NMN■EEE■E■■■ ■■■■■■■■■■.,
eMOMMEMiREMEN0 iMENESSEENO
i■N■■■■■■■■■■i=N■■■■■E■■ ■■■.■E■■■■■MME ■ ■■MEMS■.■ME■l
SEE==EMMEME=NoE " ■ ■E M a not
esMM.■.■■■■■■■■■■■■■sM.EN■■■■.N■■■■■■■■■■E■■M■ MM■■ ■=n _■ = ME■ ■■■■■■■■■■■■■i
OEM
aM■■■■■E■■■■■N■■.■■■■N■u■■■■.■c�■■■■■ ■ ■■■■■■n . ■ EiIMRM■■.■N=■■■._Mom■■■■.■MEN Eli
■a.■..■M■M■e■■.M■■ ■■....■■■..EEE■■■■MEN■EEE■■■■NMEN■■■NNEN ENOMM slow O ■N.M■■MMME'■EM■■■■■E■■mommmmali
a■■.■■■■■..■■M■.■.■MME■■■■■■■.■■■■■■■■■■■■■.■■■■ ■■■■■■■■M■■ ■.■.■■.■■■.■■ ■■■■E■.■i
■.■■■M■■.■■■.■■■■■.NM■■■■■■■■■■.■■■N■■■■■■.■■■■E=■N■■■■■E■■■M�E■E.■■■■■■■NEM ON■■■■■■I
■■■■■■■■■■.■■■■■■■■i■■■■■■■■■■■■■■■■■■■S�■■n■■■■■�■■..EEE..■ .N■ ■■■ ■■■■■.■■■■■■■EI
NOMINEE■ ■ MMS■■E�■■.■.S.■■■■■■■■■■■■■.■
::C:C:::::::::C:C:::::::::::::::::::':::::::::::::::_...■MEMO■■.�.o■■■■.■.■■.■■.■■■■■■■Nmml
S1
■■■■■■■.■..■■■■■■■■■.■■■■■■■M■■■■■■■ ■■n■�■.■■E■■E■ ilmmmmoomN■■■ ■■■.■■■■ ■■■■■■M■i
■■.■■■■■■■■■■.■■■■■■M■■■N■■■.■■■■E■■■■.■■■■■N■■ oM■ ■.■ ■■ ■■.■■■■■ ■EM■■■■■■■.Mi
■.■■■■■■■■■■.■■■■■■■■■■■■■■■■■■.■■■■■N■■■■..■E===■=M�.E.E■. ME.■■■■■ =IMEN■M■N■■■■E
■ ■
■E■■■■■■■■■EEM■■■■■■N■■N■■■■■■■■■■■■■■■■■■■a■■ ■ ■■■■■■■■N■■■■NN■■ ■■ ■■ ■■■■■ ■■
■■■■■.■■■.■■■■■.■■■■■■■M■■■■M■■■■■■■.■.N■■■■■■■■ ■■�E■■■■■■■■■■■■■.Ns■� ■■ i■■I■■■.■_■■
■■■■■■■.■.■■.■■■■■■■E■■.■■■..■=■■■■E.■■■.■ ■■■■■■■■Nn■E■.■■n■■.■■■Me■■■■■.■■■.E■■■
..........................�... ■■■■■M■■■■■ N■■■■■■.■■■■■. _.�........ .._.........�
■■■■■M■■■■■■N■■M■■M■.M■■■■ ■■■■■■■■■■N.■■■EN■■.■NNN.■N.■■M■� ■ ■■■.NEEM ■■■■N■■■■�
■■■■■■■..■■■■■■a.■■ME.■■■■■■■■■N■=■■�.■M■E■■■■.■■ ■N■■■NM■ ■=EEN■E■.■■■■ ■.■.■■■■■.i
■■■.■.■■■■.■■M.■M.■.E■■■■E■■■■■N■ ■■ ■■■■■■a■■s■■■■■■■■■E■■■ ■■.■■■■�■■■■NN■.M■■■■■.■■i
■■■.■■■■■.■■■.■■■■■■E■■■■E■■M■■EEE■Mns■aE■■■■■■■NMN■■.■E.■■■■■■■.. ■E■■■N■■■■■.■n■.i
■■■.■■■...■■■■■■■■M■■■NM■■■■■■■■■■■■.■■■■Nae■■s■■■.■■■ENE■■■E..■■■■■■E■■E.■.■■■■■■■■■i
■■■■■■■■ ■■■■.■■■■■■■■■..■■■■■■.■■■■ ■■■■■ ■..■■.MM■■■E■■■■■■■.■■.■■■■.E■ t■■■■..■M
Davie County .�lealtF department
and Nome Nealtfi ffyency
210 HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634-5985
July 30, 1996
Jimmy Boger -
185 Pinebrook School Rd.
Mocksville, NC 27028
Re: Site Evaluation
US Hwy. 158
Tax PIN: #5861-47-2872
Dear Mr. Boger:
As requested, a representative from this office visited the aforementioned
site on July 29, 1996. Based upon 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.
If you have any questions, please feel free to contact this office.
Si erely,
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RBH/wd
Enclosure(s)
Parcel#: E700000069 Page 1 of 1
Davie County, NC - Basic Estate Search ��vcz11%,
Davie County Web Site
Basic Search Real Estate Search Tax Bill Search Sales Search
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
Parcel#: E700000069 Account#:77234000
Owner Information Tax Codes
EBB WAYNE REVOCABLE TRUST&WEBB WAYNE TRUSTE ADVLTAX-COUNTY TA
1848 NORTH NC HIGHWAY 801 READVLTAX-FIRE TAX
OCKSVILLE NC 27028
Property Information Township
Ess:
(Units/Type): 0.780 AC FARMINGTON
4395 US HWY 158
Deed Information Local Zoning
Pate: 10/2003 Book: 00516 Page: 0884
Plat Book: Page:
Le al Description PIN
10.900 US HWY 158 LOTS 31-39 5861472872
Proa Values
uildin 160,65
BXF:
nd: 50,97
Market: 211 62
ssessed: 211 62
Deferred: 01
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
00190 0034 09 1996 WD Qualified Vacant 22,500
00402 0782 01 2002 WD Qualified Improved 150,000
00516 0884 10 2003 WD Qualified Improved 250,000
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
« Return to Basic Search
All information on this site is prepared for the inventory of real property found within Davie County. All data is compiled 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
implied, in fact or In law, including without limitation the implied warranties of merchantability and fitness for a particular use.
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
3 s �
http://maps.daviecountyne.gov/itsnetfView.aspx?pzid=1469449 6/15/2016