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2722 Hwy 601SAccount #: 990001259
Billed To: Trinity Church
Reference Name:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5745-69-2761 A
Subdivision Info:
Location/Address: 2722 601 S.-27028
Proposed Facility Building Property Size: 260 x 270
ATC Number: 3907
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 Fonm/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 WASTEWATER CONSTRUCTION//IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: /�l�/ Date: A0 &11A�
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.. e
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Septic System Installed By: V -
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
'S
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001259 Tax PIN/EH #: 5745-69-2761 A
Billed To: Trinity Church Subdivision Info:
Reference Name: Location/Address: 2722 601 S.-27028
Proposed Facility Building Property Size: 260 x 270
ATC Number: 3907
**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
#People #Bedrooms #Baths
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type' �J k /C/t #People j�:h #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New PTRepair ❑
System Specifications: Tank SizeA25—&4GAL. Pump Tank GAL. Trench Width'Rock Depth 'Linear Ft.� /
Other: A /Z Ay //AlUG
Required Site Modifications/Conditions:
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.****
Environmental Health Specialist's Signature: / Date:
DCHD 05/99 (Revised)
' Oct 14 04 03:14p dbC 1
• Oct 1%04 01:50p cfavie county envhealth
919-661-1523 �� p•2
338 751 e06 r. .2. (1
6D
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Deptidmht
EnAhaamental i/ealth Sea ky7
P.O. Box 348/210 Hospital Strwat
ltoaksvillo, NC 27C28
(336)751^8760
**aXKPQFTANI'ai• T=S ASDZICATION all=07 AW PROCE=SISD MMESS AU RM17YRCD
MWORnTION IS PROVIDE.!:. Refer to the INFOAIWION 33VUETIV for inatructioan.Ti�
- t-
e�l. Name to b• Gilled-�(}_©ii� l {1 U �! h Goneact Iuawa�
✓� Mfaiiirg AAdreasAall
_ _ 1-1 xome Plan
mat./sea:•/zxr�1)� ��P , auaioaaa am..
t -•R. !Yana oa paean/ArC if aiffar,mt thaw abcv.
.-.-Mailing sddraae city/itate/Up
Appliaetion For: 0 Sita 3valuativa 4 Improvezeat Varatit/ATC U/Both
U1• ayatew to SwtviteS O House LI ttobil• Home C] suaineaa ❑ Itftstry WAthepr� 7►/
L..�-S. Type syata. r veaced: i/Coarontional n corvoAtional awditiad ElLneevati" J��L(/` 41
x,16. IftfRasidenca: 0 Paoplc _ a Sadrooms a Bathrooms
—i 1Daanwaahar Dcarbage %upcsa! Owaahiry Nacai.ae �saoeaMai/elwming ❑saaemaat/No Fl—bl-9
7. If sadness/Indestry /Other: vsray type R peopla a Zink*
e Commae3 -4-% ---' w tJawrn a Vrinals '0.2— a water cowers
U FOODS&RVIC@a It Sante txtimated Water Usage (gal/oas per d..yl�610d
e. Type of water supply: Q/.:ounty/City 13 Well ❑ Cc==Lty
1. Do you anticipate addttio,.a or expansicmatthefacility tltlssystcmlibStended toserve? 0Yrs Q(No
irSyx, witat type?
••`IMP TAIPT'a• CLSENTI sff/STC ZLTBTI(C "12a IW PROPERLY INFORMAT10-1 REQLUTED
OW. .Ilher a PLAT ur u1TF: PLAN Sf T dBSIldH177ED by thccliect with THIS APPLICATION.
C�—~Property Dirneolurls.. RITC DIRECTIONS (from 17ocksrilic) to PROPCRTY:
nr Oftco PINS M �J/t� ON(
//'Property Andres:: Road Nitnit G11 cJq
Cityfb(p le ►�.Z�C..�7y 14
If in a 3ubdhiston provide inlaraaation, as follows:
Name:
Section: Brack: . Lot: _ L. -00a host corners flagged:
This is to ccrtily that the information pr ruined is correct to the best of my lnaowledge. f mtdtntand that any perSwit(r•)
issued hcrtafter are subject to suspensloa or revocation4 if floe site plats or h tcudcd use ebangc, or if flat iufonnatlon
subuaittcd in this application is lalsitfed or ebzngatl. 1, chs undcrrtaied s/tarld:uS resppasibfejo►all eHargesiacurredjrnvr
dik arplitnriora. 1, hereby, give roaseat to the Aatharizcd Ropresta tativo of flu Daric County Hcalth D%annicut
ro tater upon above described property located in Davit County and owned by
to cuuduci ail�^Usting proceduresas necesary le determaine the site sui it
/ -,- i .
DATE �V I i � C_ — C�yP'NATUiti f
THIS AREA MAY�BE USSF.D FOR DRAW= YOUR SITE PLAN,(Indudc sli of Ike following: Existing and proposed
properly lines and dinacntionr, structure;, setbacks, ant! septic location).
I !Set Revisit Charge
�o 19
Sign gi-.iu ! • y
Rek-hed DC11D (05403
Client NotiIIcatiou Date.,
J x t
Account No. / -D-5 7
Invoice No.
/V -I e
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAMES G
PROPOSED FACILITY
SUBDIVISION
DATE EVALUATED
PROPERTY SIZE �,�
ROAD NAME �Q�•S'
Water Supply:
On -Site Well
Community •
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Slope %
2.
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
moi' , 77 f
Texture group
C__
Consistence
Structure
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: U =, EVALUATION BY: Oke
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 clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Mois
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
SF - 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 (O1-90)
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iMENNEN MENNEN�CMEMNON :CG:::i�:::C::
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■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
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Parcel #: M5060B0002
Davie County, NC - Basic Estate Search
Basic Search Real Estate Search Tax Bill Search Sales Search
Vigw Property Record for, this Parcel View Map for this Parcel View Tax Bill Information
Parcel #: M5060B0002 Account #: 73806000
Owner Information Tax Codes
NITY BAPTIST CHURCH ADVLTAX - COUNTY T
EMo722 US HIGHWAY 601 SOUTH FIREADVLTAX - FIRE TAX
CKSVILLE NC 27028
Property Information
Township
Land (Units/Type): 5.310 AC
JERUSALEM
ddress: 2722 S US HWY 601
Land:
Deed Information
Local Zoning
Date: 05/2002 Book: 00423 Page: 0096
ssessed•
Plat Book: age:
Deterred:
Le al Description
PIN
5.353 AC HWY 601
5745692761
Pope Values
uildin
2,445,38
BXF•
9,03 01
Land:
4982
Market:
2 504 23
ssessed•
2,50423
Deterred:
Sales Information
No. Book Paye Month Year Instrument Quai/UnQual Improved Price
1 00423 0096 05 2002 WD Unqualified Improved 20,000
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
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oP�r�
Davie County Web Site
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
http://maps.daviecountync.gov/itsnetfView.aspx?prid=1469126 7/29/2016
t
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• P. O. Boa 848/210 Hospital Street %
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 990000963 Tax PIN/EH M 5745-69-2761
Billed To: Landmark Builders Subdivision Info:
Reference Name: Michael Johnson - Location/Address: Hwy. 601 S.-27028
Proposed Facility: Church Property Size: 4.36 Acres
ATC Number: 2308
**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 CL /(' #People #Bedrooms #Baths
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type / �C #People � #People/Shift #Seats _� Industrial Waste: ❑
Lot Size Type Water SupplyDesign Wastewater Flow (GPD)- Site: New Repair ❑
System Specifications: Tank Size/_2GAL. Pump Tank GAL. Trench Width Rock Depth ° `Linear Ft.�
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAY
FINISHED GRADE. ****NOTICE: Contact a r
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m.
d t Vi,(r 4f, wil�
/�l! `�N � d rale �ie
d;,ljr�c a C
b�
NT FILTER. RISER(S) IF 6 K BELOW
ty Health Department for final inspection of this
lation. Telephone # is (336)751-8760****
'-/ IR // J-/" 1A , 0,0, 9 / '/
AWQf kr5-
Environmental
Environmental Health Specialist's Signature: �Zve Date:
DCHD 05/99 (Revised)
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990000963 Tax PIN/EH #: 5745-69-2761
Billed To: Landmark Builders
Reference Name: Michael Johnson
Proposed Facility: Church
ATC Number: 2308
Subdivision Info:
Location/Address: Hwy. 601 S.-27028
Property Size: 4.36 Acres
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 WASTEWATER CONSTRUCTION IS VALIDR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: �� Date: 3- 06
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.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
y
Date: ?�2a -eo
'-`t^"."''.' i �waC' r: Za ,.�f k, .3. ..-.:c-a+, i .�i••:4 ,R as�a zt5't ,:5.. -. �.. }:.,^ -';�' t+, .',.c `, i _ ,..yam,....,. _._ <r: .-. _. .. -, «. .� w .a=..,.. .. -
�' YX o
0 ~' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
**MOTE** 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 B.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment,and Disposal Systems)
_a7aa
\ f (�RRDPERTY ADDRESS D. I I�L U� �. �� wy G, (X oy ("� DATE
LOCATION S o
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS / # OCCUPANTS GARBAGE DI : Yes/ o
C A t "� �• �Y 1. �; �r
COMMERCIALSPECIFICATION.'"FACILITY TYPEQ22�,& � # PEOPLE # PEOPLE/SHIFT S# SE4TS JNDUSTRIAL WASTE: Yes'No
LOT SIZE TYPE WATER: -SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
0,Q
SYSTEM SPECIFICATIONS: TANK SIZE ;GAL"; PUMP TANK GAL. TRENCH WIDTH ROCK;DEPTH ,�.� LINEAR FT.`� _
OTHER ,
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS,PERMIT IS SUBJECT %TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. ` w
^Z
~1 i
OF THE. 'DOOV
•1:30 P.M.
IMPROVE BY
I JTY-HEALTH DEPARTAENTFOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
DAY OF INSTALLATION."'TELEPHONE'#'IS (704)-634-8760.
SYSTEM INSTALLED BY,
u ° ` W 1J
AUTHORIZATION NO. L OPERATION PERMIT BY DATE
**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 BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DOHD 10/95
**CONTACT A
SEN'
8: X-9!
. M. OR
OPERATION PERMIT
^Z
~1 i
OF THE. 'DOOV
•1:30 P.M.
IMPROVE BY
I JTY-HEALTH DEPARTAENTFOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
DAY OF INSTALLATION."'TELEPHONE'#'IS (704)-634-8760.
SYSTEM INSTALLED BY,
u ° ` W 1J
AUTHORIZATION NO. L OPERATION PERMIT BY DATE
**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 BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DOHD 10/95
DAVIE COU1NTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
?bdn0n11Cbinff WOUTT
**NDTE** 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 It of G.S. Chapter 136A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
:0 �L U, Cl.
f-1 4,ROPERTY ADDRESS uj� DATE
LOCATION
SUBDIVISION NAME LOT NUMBER SEC./BLOCK NUMBER Rf
RESIDENTAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes/ o
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS IINDUSTRIAL WASTE: Yes No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GkPUMP TANK GAL. TRENCH WIDTH ROCK DEPTH
LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJEC-�TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
k o
IMPROVE LBY
'Y HEALTH DEPARTMENT FOR FINAL INSPECTION OF -THIS SYSTEM BETWEEN
',OF INSTALLATION. ``TELEPHONE # IS (704) 634-8760.
SYSTEM INSTALLED BY
7
AUTHORIZATION NO OPERATION PERMIT BY DATE
**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.
A
DCHD:40/9-5-.-
I f
**CONTACT
SENTI
8 :30-9 APPR
MM. . OR I
OPERATION PERMIT
k o
IMPROVE LBY
'Y HEALTH DEPARTMENT FOR FINAL INSPECTION OF -THIS SYSTEM BETWEEN
',OF INSTALLATION. ``TELEPHONE # IS (704) 634-8760.
SYSTEM INSTALLED BY
7
AUTHORIZATION NO OPERATION PERMIT BY DATE
**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.
A
DCHD:40/9-5-.-
I f
`.N...
-n
i e V
Davie County Health Department
.;~ ENVIRONMENTAL HEALTH SECTION _
ZJ P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System Construction oust 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 Countj,Building Inspections
Office when applying for Building Permits..***
NATE' �
1� 0 0 c DATE NAUTHDRIZAT0 2 FL1R'.9
7pvo
NAME ON IMPROVEMENT PERMIT (If different than above) t
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT,WA5TEWATER SYSTEM
*"NOTICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FOR A PERIOD,OF FIVE',(5) YEARS.
'
ENVIRONMENTAL HEATH SPECIALIST DATE
ACHD 10/95
'f 1_ .e .. .i+ . - ... �t:.-' _ ,r.v . .r 5r ._ �-. }.. 4 .i .Y•..,.. i .. , ..-.�.b.J ;,.^: i. _ _a ::�s.<V..-. .i..�w. f
v
• DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAM
PHONE NUMBER
ADDRESS Z 2 U 'S �� w &,61 S 6- L SUBDIVISION NAME
"M 0 c\<r u �� `'� �. k'I 0' - LOT #,
DIRECTIONS TO SITE Lo S " �- -73�� Q�S 15
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED�'�`"
TYPE WATER SUPPLY---LQ-SPECIFY PROBLEM OCCURRING�rc.
DATE REQUESTED y 'cl INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
r
Incurred from this application.
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PROPOSED BUILDING AND SITE IMPROVEMENTS FIIR:
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-� This dhadng Is the property oIF LwKbark Binders of the Triad Inc, and Is not to be reproduced or copied
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PROPOSED BUILDING AND SITE IMPROVEMENTS FIIR:
TRINITY BAPTIST CHURCH
CONTACT PERSON{ PAS -OR DARRELL COX (336) 284-2420
2722 U.S. HWY, 601- SOUTH, MOCKSVILLE
JERUSALEM TOWNSHIP, DAVIE COUNTY, NORTH CAROLINA
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APPUCATION FOR SITE EVAUTATION/IMPROVEMENT P
Davie County Health Department D
Environmental Healtfi Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
3C
JAN 2 6 2000
* * * IotPORTANT* * * THIS APPLICATION CANNOT BE PROCESSED UNTO Gs nT T: - TIFF 'RVoUIRED j
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
i. Name to be Billed b9yvVM-oa Rulaw6
Mailing Address 3,520 7p,0 Cat4a;r
City/State/ZIP IA)tAJ670AJ-5.-f1Q*-/Pl, Alr- 27107
2. Name on Permit/ATC if Different =%_:: Abc re �/%y► i_�h
Mailing Address
3. Application For: ❑ Site Evaluation
Contact Person ActfrfE'L =OtmjSON
Home Phone
Business Phone !L7 7'
city/state/Zip
?
Improvement Permit/ATC
4. system to service: ❑ House ❑ Mobile Home ❑ Business ❑ Industry & Other C11URC-/
5. If Residence: # People # Bedrooms # Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: Specify type CfiU/ZGf/'/'LL lklTM49by # People 36 ( # Sinks 7
# Commodes # Showers �_ # Urinals Z # Water Coolers 3
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) IM
7. Type of water supply: County/City ❑ Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes KNo
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
113 6'tc
Tax Office PIN: #
Property Address: Road Name Z722 uS* /f wy 601 St1ttT{/
city/zip lWocksvILA& 27028
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Date Property Flagged: I 2 0 0
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 T iAirry RAP,71sT CuuACA4
to conduct all testing procedures as necessary to determine the site suitability. 1
DATE SIGNATURE
THIS 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).
s I TE P LTJ 15 A-rT✓} C N-6,0
Revised DCHD (07/99)
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No.
Invoice No.
Vic►. P���U�v� ,
: ��� • aAPPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT
Davie County Health Department
Environmental Health Section
lea P.O. Box 848
Mocksville, NC 27028
(704) 634-8760
4
! ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed 7-iQ/A)ITy &4PT7S r (74UkC fi
Mailing Address Z-7 ZZ LAS 2Jq L o 1 50 u Td
City/State/Zip N6Ck6yi LLL, , n1C, 2, -7o ? -,R
2. Name on Permit/ATC if Different than Above
Mailing Address
ALL
Contact Person /04ST0k fivresC_C_, L24
Home Phone
Business Phone
City/State/Zip
3. Application For: [yJ Site Evaluation [ ] Improvement Permit & ATC [ ] Both
4. System to Serve: [ ] House [ ] Mobile Home [ ] Business [ ] Industry [ ] Other CHyP-fi
5. If Residence: # People # Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage Disposal
[ ] Washing Machine [ ] Basement/Pluinbing [ ] Basement/No Plumbing
6,00 -SEAr
6. If Business/Other: Specify type 0-1409k .A # Peopl^DM %Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: K County/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? D4 Yes [ ] No
If yes, what type? dWRCH Cl?OIU-M
"'EITHER A PLAT OR SITE PLAN-'
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** AXVffii:OF THE PROPERTY MUST BE
CLANS w Ct{--
o �D. Pu�� SUBMITTED WITH APPLICATION.
4-59 Ps—�— e-2
,Property Dimensions: 'i WRITE DIRECTIONS (from ocksville) TO PROPERTY:
Tax Office PIN: #514�5 - 69 - Z7 1_ �i W Y D ( S O t .cT KGo 1 h"u C H
Property Address: 1 Road Name 2.'1 ZZ US 14A b01 Sogj -17N-11Q S EC'ixo 0 O F Fk) y F, b 1 fhu 1�
City/Zip MOM-KSU1 LI e -,NC Z?62R 11- 1iWY RID I — n,q Lk ePCq IIZ (ki L- '
If in Subdivision provide information, as follows: D r1 121 (-� H T
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 T,2 U P I TV -g,�l S_'r-. C14 U 2 eA to -conduct all testing procedures as necessary to determine the site suitability.
DATE SIGNATURE
Revised DCHD (06-96) n
(THIS UREA MAY BEUSED TOR -DRAIVINQ YOUR 3ITE.-PLA:4
Scpe_ �ac.(oSed 01aw
EY ISSUBJECT TO ANY FACTS THAT MAY BE DISCLOSED BY A FULL
ATE TITLE SEARCH, NOT FURNISHED TO ME AS OF THIS DATE..
THIS PLAT IS SUBJECT TO ANY EASEMENTS, AGREEMENTS. OR
IF WAY OF RECORD PRIOR TO THE DATE Of THIS PLAT.
U.S. Highway 601 (south )
I>AR
Q AR EL 2 T nity Bar
D. B. 1
1 2345678910 12
1es For
'nit B tis Ch rch of avi 1 1
D.B. 6- 77
v `Poir t S 90
51 20
it
Trinity: aptistsChurch w .50
49 f �,
LEGEND
R/W — Right—of-Way
— Center Line
EIP — Existing Iron Pips
EIR — F sting Iron Rebar -
—_Mori LineXment
C PeCM
PoC
ncrote Monument
��pp�f Ole
MH Hole
IRS — Iron Rebar Set
PA —.Property Line
— Mbn
R — Radlus
C A — Controlled Access
— Chord Distance
P 0 — Part
RCP — Reinforced Concrete Pipe
— Sight Easement
CMP _Com9c
rs �p
Fl
:n
100eBoundory
-o- Cd UUI?U
—X— Fence
_W
S 39"35'00"E
2E 6.0 Ust'
DO-�270rch I I. I I
rn 0
14 IV n 18 20 22
1 5 to 19.' 21 23
6 7
5'0 "E
00'
MAN10101116161111M
LlXll-Ve61 'ON ASVA&AiUW 70111D/iM
—� 83
316.46' ��—PREUMINARY POSITION
S 48°47'05 E—� NCGS DAVIE AZ MK 2
�e vine N = 759,096.823
I E = 1,546,967.581
N10' X 2
7 5' DRAINAGE EASEMENT
N
24 26 a0� . LOT NUMBERS SHOWN REFER TO PLAT OF HOLIDAY ACRES, SECTION 1
'a RECORDED IN PLAT BOOK 3, PAGE 108
2*03 O
CP 0 100 0 100. 200 300
NIP GRAPHIC SCALE FEET
10.c �
PARCEL 3 48 43 4 66.40' 5 3 31 29 28
47 Z 2°0 20 w 3 3 \
22 4 N
f-._
$41 ° 15.2 E ~ P°�� \
L� olntl 4FAR EL 4
a�0 45 o-
( 30' to CL �—
1 2 �
3
2 187 AN0 W irH 60uA0 SLCIG,
2.403 ACRES ( by d.m. db ` ) _
�r� l
SCALE
J 1, C. Ray Cates, certify that under my dlrtriNgpGihd;C� ��
supervision, this map was drawn from an gE°+u,.f•Petd, 1. = 100
survey.
.��'Q���STF9�O:y
SEAL
3 SURVEYED:
L-2623 0 CRC
Registered Land Su veyor L-2623
o`
' •'•.�D .Ito MAPPED:
PLAT FOR
Trustees for.. _
Trinity Baptist Church.
PART OF DEED BOOK 170, PAGE 681
PORTION OF PARCEL 3 AND 4, DAVIE COUNTY TAX MAP. M-5-6.-I..
TOWNSHIP COUNTY STATE
DATE
Jerusalem Davie North Carolina 0
2 0 8 9&.:
02-1,9�9�;
C. Ray Cates
119 Depot Street
JOB NO.
1121
Mocksville, NC 27028
MAP N0.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT,
Soil/Site Evaluation
APPLICANT'S NAME
/t
PROPOSED FACILITY
SUBDIVISION
Water Supply:
Evaluation By:
On -Site Well
Community
Auger Boring �� Pit.
DATE EVALUATED���%
PROPERTY SIZE
ROAD NAME
Public
r�
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position ,L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH i 7
Texture group
Consistence
Structure C-..4 -'e
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: L
REMARKS:
DCHD (O1-90)
LEGEND
Landscape Position
EVALUATION BY:
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
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
SS - Slightly sticky S - Sticky VS - Very Sticky
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
MENEM
MENEM
mommm
mommomp
MEMEMEN
MEMENEW
MENNEEM
MEMMEME
MEMMEME
mommmom
MENMEME
MEMMOME
EMENMEM
mommumm
moommon
MEMEMEM
Emmomms
MEMENNE
MMEMEME
MENNEME
MENMEEM
MEMENNE
mommoom
NNE
MEN
NNE
ONE
MEN
ENNNEEMEMEMEMEMEMEM
ENNNEEMEMMEMMEMENEM
MENNUMMENEEMEMEMEN
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Davie County HeaCth Department
and.Come Health Agency
Environmenta[Heaf& Section
P.O. Box 848 / 210 HOSPrrAL STREET
COURIER #09-4-06
MOCKSvaLE, N.C. 27028
Trinity Haotist Church
Attn: Darrell Cox
272E U.S. Hwy. 801S.
Mocksville, NC 27028
Dear Client:
As requested, a representative from this office visited the
aforementioned site on May 27, 1997. ' 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 systema
If you have any questions, please feel free to contact thisoffice.
RH/wd
Enclosure(s)
DAYIE COUNTY HEALTH DEPARTMENT
w ,
,;.-'• (Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorvtion Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR I +l r* .� "' - fi
C DATE PERMIT
�oISN° 731
LOCATION l Li T f" :°� .
,,r S.R. N0,
SUBDIVISION NAME t /,' iw r=.+ LOT NO, SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME BUSINESS
House Trailer 800 Gal. 400 Sq. Ft.
NO. BEDROOMS N0. BATHROOMS Two Bedroom House 800 Gal. 1600 q. Ft.
GARBAGE DISPOSAL UNIT YES ❑ NO ❑ Three Bedroom House 9 Gal. 900 Sq. Ft.
AUTO. DISHWASHER YES ❑ NO ❑ Four Bedroom House 000 Gal. 1200 Sq. Ft.
AUTO. WASH-. MACHINE YES ❑ NO ❑ �^•
SITE SUITABLE YES [3NO ❑4
SIZE OF TANK,p gal.S'r
V fN +� . <,
NITRIFICATION FIELD Sq. ft..
C 1 i1 j e S ! : b . ey.,
DEPTH OF STONE IN LINES:
WATER SUPPLY 'Individual Public ❑
ft
3&;1Jc6 !da X 3
IMPROVEMENTS PERMIT BY INSTALLED BY --T
CERTIFICATE OF COMPLETION
BY—
(8/16/73) *Construction must
LOT AREA
t
t- VN\" Date d, -2-7 - 2 f-
ly
ly with all other applicable State and local regulations
�I DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name 7r�� �a ri �S � Gy�u.►`c� Date % 9 1
��
Location (00is
d22 us &W -Y &WS
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:--�fsao��«4��!'� l
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑ p,c-f'�Qv}L_- ,Zr�rf1C8 aC�S�
Type Water Supply C' L,� w°���- _— �tsdlon
T'1J<c C� tG nec'ed= for
to S,tn leu. ' C)V%.:
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
4-1I
ti. _
jr
Improvements permit by �` `ti' �, a• ., ��.
*Contact a representative of the Davie County Health Department for final inspection of this system between. 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
*The
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
System Installed by 7ig& mkhy'# �
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
P.O. BOX 5a,
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEIMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVALUATIONS
NAME Rtt3. Cyr..e letcXur h DATE ► . _ . _ [ yy�
ADDRESS O r.,:.�1 s`y=e �'; ; C,1. PERMIT NO. ;
EXPLANATI014 OF CF.ARGE '; .>' �; , — 1 • �, �` _�,'C :CT A
+- � y tet.; .
AMOUNT DUE 2, .,"O SANITARIAN C YN-\c, a
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be completed until payment is received.
Improvements Permit(s) can not be issued until payment is received.
