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3580 Hwy 158 (2) Davie County,NC Tax Parcel Report Friday,November 18, 2016 ......................................................................................................................................................................... .......................................................... .................................................................................................................................................. WARNING: THIS IS NOT A SURVEY Parcel Number: F60000005316 Township: Farmington NCPIN Number: 5850799819 Municipality: Account Number: 8300111 Census Tract: 37059-803 Listed Owner 1: COLLIER MICHAEL WAYNE Voting Precinct: SMITH GROVE Mailing Address 1: 148 SPARKS ROAD- Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overlay: DAVIE COUNTY QD Zip Code: 27006-0000 Voluntary Ag.District: No Legal Description: off hwy158 Fire Response District: SMITH GROVE Assessed Acreage: 6.91 Elementary School Zone: PINEBROOK .Deed Date: 2/2011 Middle School Zone: NORTH DAVIE Deed Book Page: 008510664 Soil Types: MrB2,EnB,RwA,MsD Plat Book: 10 Flood Zone: Plat Page: 217 Watershed Overlay: DAVIE COUNTY Building Value: 0.00 Outbuilding&Extra 0.00 Freatures Value: Land Value: 53630.00 Total Market Value: 53630.00 Total Assessed Value: 53630.00 All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, 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 161 NC or arising out of the use or Inability to use the GIS data provided by this website. OPERATION PERMIT EEvaluated ice se n v. Davie County Health Department Number 219238-1 210 Hospital Street ' umber: P.O.-Box 848 Mocksville - NC 27028 or. NEWPhone:336-753-6780 Fax:336-753.1680 Applicant:- Randy Grubb Property owner: Nick Gretka Address: 130 Kent Lane Address: 3580 Hwy 158 City: Mocksville COY Mocksville State2ip: -NC 27028 State/Zip: NC 27028 - Phone#: (336)940-8491 Phone#- PropeLly Location & Site Information :... ... Address/Road #: Subdivision: Phase: Lot 3580 Hwy 158 - Mocksville NC 27028 Directions Structure. SINGLE FAMILY Hwy,158 East - - -: #of Bedrooms: 5 #of People: 'Water Supply: NEW WELL Y "IP Issued b 2140-Nation,Robert *System Classification/Description: 7 TYPE Ill G.OTHER NON-CONN.TRENCH SYSTEMS 'CA issued by: 2140-Nations,Robert SaproliteSystem? GYes ©No Design Flow: 6 0 0 *Distribution Type: GRAVITY-SERIAL PumpRequired QYes No ...Soil Application Rate: - - 0 a 'Pre-Treatment: Drain field Nitrification Field 3 0 0 0 Sq. ft. 'System Type: INFILTRATOR OUICK 4 STANDARD No. Drain Lines 6 Installer: Brian McDaniel Total Trench Length: 7 5 a ft. Certification#: 1118 Trench Spacing: — 9 Inches O.C. Feet O.C. "EH S: 2140-Nations,Robert Trench Width: 3inches gFeet Date: 1 1 / 0 4 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover, 2 4 Inches Approval Status Maximum Trench Depth: 3 6 Inches ® .Approvetl 0G=Disappt'oved Maximum Soil Cover: a q. Inches CDP File Number 219238 - 1 Septic Tank County ID Number: Manufacturer. Shoaf Lat. X Long: STB: 363 Gallons: 1250 Installer: Brian McDaniel Certification#: 1118 Date: 0 9 / 1 8 / a 0 1 6 *EH S: 2140-Nations.Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker: _❑ Yes 2 No Date: 1 1 / 0 4 / 2 0 1 6 Reinforced Tank: ❑ Yes _ ® No Approval Status Piece Tank---' ank: p Yes D No" ® Approved El-,Disapproved - Pump Tank Manufacturer. Installer: PT: Certification#: Gallons: *EHS: Date: / / Date: s Riser5ealed ❑ Yes ❑ No Riset. ❑ YeS ❑ No (Mi in.) App rHeglrovat Status Reinforced Tank:-❑ Yes Cl No Q A roved❑ Dtsa roved Pp PP. 1 Piece Tank_ ❑.....Yes--- _ -- ❑ No- Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: *EHS: *Schedule: Pressure Rated ❑ Yes El No Date: Approved fittings ❑ Yes ❑ No ApprovalStatus Approved❑`.Disapproved Pump e u ent ( Pump Type: Installer: Dosing Volume: — Gal Certification Draw Down: Inches *EH S: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ N o Check-valve ❑ Yes ❑ No .Approval statusw PVC unions [3 Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole El Yes 0 NO CDP File Number 219238 - i J County ID Number: Electric E uI ment NEMA4XBoxorEquivalent ❑ Yes ❑ No Installer: Box 12 inches Above Grade ❑ Yes ❑ No Certification#: Box Adj.To Pump Tank ❑ Yes ❑ No 'Conduit Sealed ❑ Yes ❑ No IEHS: Pump Manually Operable ❑ Yes ❑ No "Activation Method: Date: , Approval Status, _ Alarm Audible 'Yes ❑, No _ Approved❑ DlsapDroved: Alarm visible ❑: Yes ❑ "No 2140•Nations,Robert 'Operation Permit completed by: -- _Authorized State Age Date of Issue: 1 1 / 0 4 / 2 0 1 6 Owner/Applicant Signature: This'system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules'for ewage Treatment and Disposal,15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and{ Construction Authorization.This property is served by a TYPE Ill G. sewage septic system. Rule.1961 requires that a Type,-,TYPE 111 G. septic system meet the following criteria: Minimum System Review ByThe local Health Department: N/A - M anagement_Entfy: OWNER Minimum;System Inspection/Maintenance Frequency ByCertified Operator: N/A Reporting Frequency By Certified Operator.NIA Rule.1961 requires that a.Type IV and V septic systems designed fora home/business owner must maintain a valid contract.-___. with a public managemententity with a certified operator or a private certified operator for the life of the septic system. Rule .1961 requires that Type VI septic systems designed for a horne/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity,unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as tong as the system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing almport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department CDP File Number: 219238 " 1 210 Hospital Street P.O. Box County File Number: Mocksville NC 27028 Date: J Q Inch iin Scale: . 0Block Draw Drawing Type: Operation Permit - . 0N/A 1 I _ 17 T1 -LL --C�D i t4 ,u � I i 1 i , RECEIVED WELL CONSTRUCTION RECORD FnrIntemaluseONLY. � 2016This form can be used for single or multiple wells OCT 1.Well Conti actor Information: /f/� L� J t� 14.NATER ZONES /'�/� "T /1 O In/ � Zt/ rR0\I TO DESCRIPTION Well ContractorNName � ft 7 ft 31 g ft. �7,q ft. � T NC Well Contractor Certification Number 15.OUTERCASING farmulti-ease ivells ORL1�lEIi ifa liesble rRO11 TO MF ILTER T73ICC4iE55 ALATERUL Yadkin Well Company, Inca f ft in. Company Name 16.INNER CASMGOR.TUBING c7osed-loonl Q TO DLAriIETER TIIICHNESS MATE•RLAL 2.Well Construction Permit 4: q ,1 z J (� ft S y ft 6� in. List all applicable well constructionpermirs(t e.Cotmry,State,Variance,eteJ ft. 3.Well Use(cheer:well use): FROM 17.SCREEN Wa ter Supply Well: FROM TO DI-kMETER SLOTSIZE THIC'ITIESS MATERIAL ❑Agricultural ❑Municipal/Public ft. t in ❑Geothermal(Beating/Cooling Supply) Mesidential Water Supply(single) ft ❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT MOM TO MATERLAL LWPLACEMENTMETAODRAMq ❑hri�ation ^ /� Non-Mrater Supply Well: Q ft ''� 3 it r�ti�L 6 raw t; f �^ ❑Monitoring ❑Recovery ft ft. Injection Well: ft ft ❑AquiferRechaae ❑Groundwater Remediation 19.SAND/GRAVEL PACIi ifa liable) ❑Aquifer Storage and Recovery ❑Salinity Barrier rROAI I To rIATERLAL rMPLACEMENTIVIETHOD ft ft. ❑Aquifer Test ❑Stotmwater Drainage t. ft ❑Experimental Technology ❑Subsidence Control 20.I)rrLLINGLOG attaehadditiona156eetsifaecessa ❑Geothermal(Closed Loop) ❑Tracer MOM TO DESCRIPTION(calorhardnesr,sail/rack type,eralnsize,etc. ❑Geothem,al(Heating/CoolingRetunl) ❑OQ1er(explain under P21 Remarks) p �jp ft ft. f 4.Date SYeil(s)Completed: '- pWe]lID9� "�(' / ✓ r+S/L �//,f p^ ft I ft W' /su7 at s' Sa.Well Location- Phone number 1iWe E O p fL LIT-ft. ft. Facility/Owner Name Facility MR(ifoonlic Tel ft ft 3r� ��wJb /5Xchr. ft ft Physical Adddeess,City,and Zip 21.RE MARKS K I GiitiG L T County Parcel IdentificatianNo.(PRT) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ('dwell field,one lat(long is sufficieat) 67 52 N w Signature ofCertifiedWell Contactor Date 6.Is(are)the well(s):Permanent or ❑Temporary By signing this form,I hereby cert that the wells)jias(weere)consAwtcted in accordance wf1.1 ISANCAC 020.0100 or ISANCAC 02C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or PO copy ofthis retard has been provided to the well owner. 7 ibis is n repair,fill out 1=1171Ire,/construction n forntaiion and ecplain the nnterre ofrlie repair wider 921 remarks section or on the back of this form. 23.Site diagram or additional well details: You may use the back of this page to provide additional well site details or well 3.Number-of wells constructed: construction details. You may also attach,additional pages ifnecessary. Fornndtiple injection ornon-watermpp4 swells ONLYwith Me same catstraclion,you can submit oneform. SUIRUITTAL INSTUCTIONS 9.TotalWell depib bflow Jand surface: U (ft.) 24a. For All Wells: Submit this form-within 30 days of completion of well For mrrldpie cells list all Apihs lfdipzrerN(ecnmple-3@?00'and 2 r�'t 100) construction to the following.• 10.Static tenter level below top of casing: (ft) Division ofil'ater Qunlity,Information Processia;Unit, If uaterlevel is above casrito use"+" G / I/ 1617 Mail Service Center,R.'deigh,NC 27699-1617 11.Borehole diameter: (in.) Bit Of f &j. b 24b.For Iuiection Wells: In addition to sending Ilia form to the address in 24a - '"` " above, also submit a copy of this form within 30 days of completion of well 12.Well coustructiun melliud:_ RO tar V construction to the following (i.e.auger.rotary,cable,duw:c4Pus%etc.) Division of Water Quality,Underground Injection Control Program, FOR MATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 13a.Yield(gpm) Method oites#: t t tr 24c.For Water Sunnly 8•Injection Wells: In addition to sending the form to r>I-- the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: HTH Amount: Cups completion of well construction to the county health department of the county �- where constructed. /"16 & Ze Fomi GIV-1 North Carolina Department ofEnvironment and Natural Resources-Divisioa ofvlater Quality Revised lan.2013 Date Site Visited: By Builders ,Name:. R4 14 ecJ 61"A Owners Name: Address: <'K e-- Address: i Phone Number: Phone: Cell Number: bol 1Se 1 ����-w r1` u Well Construction Permit For Office Use Only Davie County Health Department *CDP File Number 219238 210 Hospital Street PIN Number. P.O. Box 848 Mocksville NC 27028 Tax Lot#: Tax Block#: - Phone:336-753-6780 Fax:336-753-1680 Evaluated For: WELL- PERMIT VALID UNTIL: 6/7/2021 PmportyOwner. Nick Gretka Applicant: Randy Grubb Address: Address: 130 Kent Lane City: City: Mocksville State2ip: State/Zip: NC 27028 Phone#: Phone#: (336)940-8491 Property Location & Site Information Address/Road#: crg� Subdivision: Phase: Lot: Randy Grubb *Proposed use of Well: Mocksville NC 27028 If Other: Latitude Longitude Directions Site Address: Randy Grubb Directions: Hwy 158 East Well Contractor information Drilling Contractor C-- Driller Registration e [✓ `Y � , . . . . . L_ . . . . . . . . . . . . . . . . . . . Z,.Aeff 7/ ermit Conditions *Permit Conditions Saprolite septic system.100 foot setback minimum Well location,construction and protection must meet all state and local regulations and must be inspected and approved by an authorized representative of the Local Health Department.The permit may be revoked at any time for failure to comply with existing regulations.The siting of approved well construction area(s)by the Health Department is to provide protection from the knavn possible sources of contamination.The approved well area(s)may not be changed without written permission from an authorized representative of the Local Health Department.No volume of quality of water is guaranteed by the Health Department. *Issued By: 2140-Nations, Robert *Date of Issuei 0 , 6 1 / 1 0 1 7 1 / 1 2 1 0 1 1 1 6 Authorized State Agent 7 * Hand Drawing Oimport Drawing Owner/Applicant Signature: **Site Plan/Drawing attached.** WELL CONSTRUCTION PERMIT 219238 Davie County Health Department CDP File Number: 210 Hospital Street P.O. Box 848 County File Number. 4 « »„ Mocksville NC 27028 Date: 06 / 07 / 2016 0 inch Drawing Type: Well Permit Scale: OONAck , � ft. f f-- i . � N SI �-ic � i LEE I WELL.CONSTRUCTION PERMIT Davie County Health Department CDP File Number: 219238 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 6 / 0 7 / 0 1 6 �f G4w� 0 Inch Drawing Type: Well Permit Scale: , a OBlock QN/A ft. - p I Z-1 S a CONSTRUCTION For Office use Only •AUTHORIZATION *CDP File Number 219238- 1,Davie County Health Department County ID Number: 210 Hospital Street Evaluated For: NEW P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 6 / 0 8 / a 0 a 1 Applicant: Randy Grubb Property Owner: Nick Gretka Address: 130 Kent Lane Address: Hwy 158 East City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: (336)940-8491 Phone#: Property Location & Site Information Address/Road#: �D Subdivision: Phase: Lot: Randy Grubb Rwy 16V I✓"+ Mocksville NC 27028 Directions `Structure: SINGLE FAMILY Hwy 158 East #of Bedrooms: 5 #of People: "Water Supply: NEW WELL System Specifications Minimum Trench Depth: 3 6 r ssification: Provisionauy suitable Inches Minimum Soil Cover: System? (&Yes ONo a 4 Inches low: 6 0 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 , a Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-SERIAL TYPE III A.CONV SYSTEM>480 GPD(EXCLUDING SFD) Septic Tank: 1 a J G 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: O Yes ®No O May Be Required Nitrification Field 3 0 0 0 Sq.ft. Pump Tank: Gallons No. Drain Lines 5 1-Piece: OYes ONo Total Trench Length: 7 r, 0 ft GPM—vs— ft. TDH Trench Spacing: Inches O.C. — 9 Feet O.C. Dosing Volume: Gallons Trench Width: — 3 OInches ®Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-II Septic Tank Installer Grade Level Required: 01 011 0111 O IV Page 1 of 3 CDP File Number 219238 - 1 County ID Number: ❑ Open Pump System Sheet Repair System Required:®Yes O No ONO, but has Available Space CDesign System O Inches O. . Trench Spacing: fication: Provisionally Suitable — Feet O.C. Trench Width: O Inches w: 6 0 0 — 3 (�Feet Soil Application Rate: 0 Aggregate Depth:a inches Minimum Trench Depth: 3 6 *System Classification/Description: Inches TYPE III A.CONV SYSTEM>480 GPD(EXCLUDING SFD) Minimum Soil Cover: a 4 Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25%REDUCTION Maximum Soil Cover: a q, Inches Nitrification Field 3 0 0 0 Sq.ft. No. Drain Lines 5 *Distribution Type: GRAVITY-SERIAL Total Trench Length: ft Pump Required: Oyes O No ®May Be Required rJ 0 Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. R-,m g 750 *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 governing bodies in meeting their requirements. Rmain�g 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been completed during the period of validity of the Construction Permit,the information submitted in the application for a permit or Construction Authorization Is found to have been incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become Invalid,and may be suspended or revoked(.1937(8)).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? O Yes O No Applicant/Legal Reps. Signature• Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 6 0 8 x 0 1 6 Authorized State A Malfunction Log OYeS r ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department CDP File Number: 219238 - 1 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0 6 / 0 8 / .20 16 O Inch Drawing Drawing Type: Construction Authorization Scale: . • • O Block O N/A ............................ . ............................ .....................................................i................. ................ _ ,..................................................7..................................,..................................,................. ..................................1................................f ................................ ................................ ........ ......... .................................................................:................................................................................... 1..................................................._............................_.................4................. ..................................................1....................... .......... ............... ................ .................... .. ................................ ................................................_'...................................................,................ ... ....�. ..................................I i .......... .............. ........... 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C . ... ......... ... ................. ... ...... l I I ..................................................................................... ................... ...................._._......... �... ........................................ Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department ' 210 Hospital Street CDP File Number: 219238 - 1 P.O.Box 848 Mock sville NC 27028 County File Number: / r — / Date: 1.6./ .0.8. /..1.0.1.6. Click below to import an image from an external location: Drawing Type:Construction Authorization w l 1 r Page 3 of 3 P1 P2 IMPROVEMENT PERMIT x For Office UseOnly CDP Fite Number 219238- 1, 06�5- 'Davie County Health Department 210 Hospital Street County ID Number. P.O. Box 848 Evaluated For NEW Mocksville NC 27028 Township: Phone:336-753-6780 Fax:336-753-1680 PERRIIT VALID UNTIL 6/8/2021 *NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit. Applicant: Randy Grubb Property Owner Nick Gretka Address: 130 Kent Lane Address: Hwy 158 East City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 i Phone#: (336)940-8491 Phone#: Property Location & Site Information Address/Road#: Subdivision: Phase: Lot: Randy Grubb Mocksville NC 27028 Directions Structure:. SINGLE FAMILY Hwy.158 East #of Bedrooms: 5 #of People: *Water Supply: NEW WELL System Specifications nitial S stem *SiteClass liica an: Provisionally Suitable Minimum Trench Depth: 3 6 Inches Saprolite System? QYes ONo Maximum Trench Depth: 3 6 Inches Design Flow: 6 0 0 Septic Tank: 1 -1 5 0 Gallons Soil Application Rate: 0 2 1-Piece: OYes QNo 'System Class ificatan/Description: Pump Required: OYes QNo OMay Be Required TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFD) Pump Tank: Gallons 'Proposed System: 25%REDUCTION 1-Piece: OYes ONo Repair System Required:@Yes ONo ONO, but has Available Space Repair System *Site Classification: Provisionally Suitable Minimum Trench Depth: 3 6 Inches Soil Application Rate: 0 a Maximum Trench Depth: 3 6 Inches u *System Classification./Description: Pump Required: OYes ONo O May be Required TYPE III A.CONY SYSTEM>480 GPD(EXCLUDING SFD) *Proposed System: 25%REDUCTION Pagel of 3 CDP File Number 219238 - 1 County ID Number: *Site Modifications ❑ open Fin sheet No grading or construction 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 governing bodies in meeting their requirements. Site Plan The Improvement Permit shad be valid for 6 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 location of the facility and appurtenances,the O a site forthe proposed wastewater system,and the location of water supplies and sur acewaters). Plat The Improvement Permit shad 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 morethan 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 lots 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 Health Department 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(NCGS 130A.336(fj).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: 2140-Nations,Robert Date of Issue: 0 6 0 8 .2 0 1 6 Authorized State Agent: OValid without Expiration? OCre ate CA. ®Hand Drawing Olmport Drawing x�f, **Site Plan/Drawing attached.** Page 2 of 3 IMPROVEMENT PERMIT 219238 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: l 01nch Drawing Drawing Type: Improvement Permit Scale: . 0131ock 4 QN/AL�L i IL 7 -zj l L, -'; �_. IMPROVEMENT PERMIT Davie County Health Department 210 Hospital Street CDP File Number: 219238- 1 P.O,Box 848 Mocksville NC 27028 County File Number: Date: ,0A 6 / %0 8 / 2 0 1 6 Click below to Import an image from an extemal location: Drawing Type: Improvement Permit ���+,�APPLICATION FOR SITE EVALUATIONAWROVEMENT PERNIIT " � TC c t f Davie County Environmental Health P.O.Boz 848/210 Hospital Street r — �� Mocksville,NC 27028 (336)753-6780%Fax(336)'753.1680" Application For: ❑Site Evaluation/Improvement Permit ❑Authorization To Construct(ATC) CST Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT"**THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION // Name to be Billed G� '–� Contact Person a ;� ',ate Billing Address Home Phone City/State/ZIP -e Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip / PROPERTY INFORMATION *Date House/Facility Comers Fla ed( NOTE: A survey plat or site plan must accompany this application. Included:❑Site Plan ❑Plat(to sc (Permit is id f 60 m nths with,site plan,no expiration with complete plat.) Owner's Name `e 77 Phone Number Owner's Address City/State/Zip Property Address 7 0 7 T—City_ Lot Size Tax PIN# Subdivision Name(if Me)e) —� S ctr vim_ Directions To Site: amv If the answer to any of the following questions is`yes",supporting documentatimust be attached. Are there any existing wastewater systems on the site? ❑Yes Does the site contain jurisdictional wetlands? ❑YesFNo Are there any easements or right-of-ways on the site? ❑Yes Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be generated? ❑Yes No IF RESIDENCE FILL OUT THE BOX BFLQW #People #Bedrooms S #Baooms _ Garden Tub/Whirlpool❑Yes o --] Basement:❑Yes BNo Basement Plumbing: ❑Yes CNo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals a�...3;4c(b'al Uriti"y' l�j� a->..-cs.+zr '.i`i 3'L� `:1Cat JL L`'.... ..::t:d�iiij`Wdti f �.' FOODSERVICE ONLY#Seats Type system requested: /Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type:❑County/City Water dewwell Misting Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes CENo 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 of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable lawsW' g, at I am responsible for the proper identification and labeling of property lines and comers and inthe house/facility location,proposed well location and the location of any other amenities. p owner's or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given ❑Yes❑No Account# a l `.A Revised 11/06 Invoice# �LIT I I0 XV I Y I I � 1 I I I 1 I I I 1FE r�- Niply . I I I I . I IFt L pd, Davie County Environmental Health Iia IvP.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT Account #: 989900414 Tax PIN/EH#: 5851-80-6527.01 Billed To: Tim Smith Subdivision Info: Address: 137 Boger Road Location/Address: Big Oak Lane-27028 City: Mocksville Property Size: 5 acres Reference Name: Proposed Facility: Residence **NOTE**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 f Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to revocation if site plans,plat or the intended use change. Permit Type: flew ❑Repair ❑Expansion Permit Valid for: &-Years ❑No Expiration r Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):30Type of Water Supply: ❑County/City ❑Well ❑Community Well Site Modifications/Permit Conditions: System Type LTAR Initial Repair Site Plan 1 n \ Environmental Health Specialist Date6�—Ivmd i.p.11-06 • TCS SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Ap licatio I uation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both Typ of Applicati New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility FINI' ORTANT***THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED FORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed 77M 5m i Contact Person Bilkifig Address i 3 '7 1) r'cJ Home Phone r/yc� City/State/ZIP l'N,n,,�(�,�,f�E /�( L Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged &djq 0 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name ' _S Phone Number 3Z'._Sk Owner's Address- 7 City/State/Zip %V.6; ,-.3t 7e.2� Propert res l3.'c� �' J,I��G%t City lie, Lot tze �- lC�^r-,"7,3Tax PIN ,'S!- c Subdt ' . pplicable) Pe«u� Section/Lot# �s� 1YI Directions To Site: I5 Z,; 4d V k,W aC= 31-71 V r CIZIAJ If the answer to any of the following questions is"Yes",supporting documentation must be attac Are there any existing wastewater systems on the site? _Yes _0o Does the site contain jurisdictional wetlands? _Yes ZNo Are there any easements or right-of-ways on the site? _Yes jzNo Is the site subject to approval by another public agency? _Yes Vf4o Will wastewater other than domestic sewage be generated? Yes_iNo IF RESIDENCE FILL OUT THE BOX BELOW #People a #Bedrooms —3 — #Bathrooms. Garden Tub/Whirlpool ❑Yes PNo Basement: ❑Yes [- o Basement Plumbing: []Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business — Total Square Footage of Building _#People # Sinks #Commodes it Showers #Urinals Estimated Water Usage(gallons per day)`_____`__(Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: ❑Conventional ,Accepted ❑Innovative EAlternative ❑Other Water Supply Type: ❑ County/City Water I/New Well PExisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes mho 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 falsifies' or changed. I hcrch_•grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and fl ing o5 stuki g the seHf.cility location,proposed well location and the location of any other amenities. Site Icevisit Charge Property owners or owners legal representative signature Date(s): _ Client Notification Date:^_ Date EHS: _ I Sign given ❑Yes ONO Account# Vj&OWI Revised 11/06 Invoice# � _ GtxMAPS - Davie County NC Public Access Page 1 of 1 Davie County, NC - GIS/Mapping System oa.�lF _ Click Here To Start Over my, Quick Sears h:(C nunYy II) nr Ow ner N. A, liveLayer. [IIKe `lap rrpt 8 ® --❑�yyPARCELS (Map Tips Available) Add re 9hi SMAY BAr_ Raj® t r� I. �� i�� �;9 D� (aAle-- (/4T http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=412... 2/24/2010 Map Frame Page 1 of 1 Davie County, NC - GIS/Mapping System OPs��F f+ f' Click Here To Start Over Quick Search:(County ID or Owner Ni to :1 Active LaE-Iyer. ❑� Use +tap Tips PARCELS (Map Tips Available) v Addre -I�ICI�C7YZ1C 3Q37 YYi1`_----- ;60000010902 1Y 43.507 AC HOWARDT( v +J A~? - L SpAGGY BARK LN �f/ I_C IU O . IT t http://maps.co.davie.nc.us/GoMaps/map/mapframe.cfm?CFID=4129&CFTOKEN=616408... 2/24/2010 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION ZROPERTY INFORMATION fim .v7 l3,� c9aac 2a,1ch, t, - r Pic &VOAT 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 (>F Structure Mineralogy HORIZON H DEPTH Texture group C L Consistence Structure Mineralogy HORIZON III DEPTH Texture group .L Consistence l) Structure All Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 05 EVALUATION BY: LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: pt o 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 41St 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 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 NQ:tes 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 05/05(Revised) t ■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■e■■■/tee■■■■■■■■■■■■i■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■I■■■■■■■■■■■■■■■■■■■■Ni`J■■■■■■■■■■■■Ile■■■■ ■■■■■■■■■■■■■■■■■■■■■■■I■■■■■/■■ ■■■■■■■■■■■■■"�■■!"_1■■■■■■■■1111■■■■ ■■■■■■■■■■■■■■■■■■■■%■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■11■■■■■ ■■■■■■■■■■■■■■■s■■■Ile■■■■■■■■■■■�1■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■11■■■■■■■■■■■■ell■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ MENNENl MMMMMiil MMMMMMM MENNENEMMONSMENNENMENNENl� ■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■■i■eft■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■i`X11■■■■■■■■■■■■■■■■■■■■■■■e■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■'X11■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ^tq� Filed for registration at o'clock M. yS` \� 2010 and recorded in RD.B. 5 Z,S. s7. 356lJ � `` D.B. 60Y, FC. 368 EXIST ING BIG OAC LST. 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