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AUTHORIZATION NO ',` ' '�, DAVIE COUNTY HEALTH DEPAR MENT '�
` Environmental Health Section PROPERTY INFORMATION
Permittee's t.. P.O.Boz 848
Name: �" - Mocksville,NC'27028 Subdivision Name:
"� ; Phone# 336-7517-876
0
Directions to property: ) Section: Lot`
r � ' AUTHORIZATION FOR
C WASTEWATER
a SYSTEM CONSTRUCTION Tax Office PIN:# - -
C>^-� Road Name {� j*' .".� Zip;
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Buil ding-Pen-nits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits:
(In compliance.with- icle 1'`of G.S.-Chapter 130A,'Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
( ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
`• , �.-,:;, t7tJ IS VALID FOR A PERIOD OF.FIVE YEARS.
ENVf ¢N�IES TAL HEALTH S LIST` DA E IS UED
'm7c i '{ .. � - ure�aty's'?..Fw —^."„,.^4,gi►.x�R"r''..^":•�9�f� ".ti�/ .+y^"�5.2-�`"�,a1•.7��+;^TAv"'f"(" �
y � � _•3,�i y���. f �- < ee��,� •• - � _, vcP,�iti .. �••7.i9—�O� i M. M+y��S.P.f'' - i,.
” i,. , ' •` ; r 24 DAME CO TY HEALTH DEPAI I MENT
t TMPROVEMENT-AID OPERATION PERMITS PROPERTY INFORMATION
`� .. --
1 Permlttee's11
,-..:; .
Name:''a ' Subdivision Name.
Directions to property: ti'`
'„�. � Section: Lot:
et E%1PROVEMENT
fY 4` "� � & "° •a PERMIT Tax Office PIN:#' _
ay Road Name }ice.,lig€** I zip: •
**NOTE**This Improvement Permit DOES NOT authorize the construction or.installation.of aseptic tank system or any wastewater system.An -
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must'be'obtained.fiomthfs Department prior to the
construction/installation of a system or•the issuance of a building peffr tL
(In compliance -Article 1'of G.S:Chapter.130A„Wastewater.Systems,Section.1900 Sewage Treatment and Disposal Systems)
'p**NOTICE***:rMS PERfar IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.-YOUR WASTEWATER
O k- HEALTH S IALIST DA IS UED SYSTEM,CONTRACTOR MUST SEE THISPERMIT.BEFORE
INSTALLING TIIE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE: #BEDROOMS L#BATHS',2�— #OCCUPANTS "2-: GARBAGE DISPOSAL.Yes or No
COMMERCIAL SPECIFICATION. FACILITY TYPE #PEOPLE. a #PEOPLF/SHIFr #SEATS INDUSTRIAL WASTE:Yes or No
. Ioox1Sa R..
LOT'SIZE TYPE WATER SUPPLYi) TY'DESIGN WASTEWATER FLOW(GPD) NEW SITE " REPAIR SITE• ` '✓
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH 340 ROCK DEPTH- LINEAR FT.
OTHER ' TASTQ1 lJVlTI1014 " 5OX.'
REQUIRED SITE MODIFICATIONS/CONDITIONS:' ��14LL 0e4 � (af o�-� P
IMPROVEMENT PERMIT LAYOUT
• ROVED EFFt lJENT FlOtR* *RISER(S): IF 6• BELOW FINIS*D, OWE*
IC-400
2'9t-
**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 THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760. ,
xxgxXxxxx
(=)751rt-876®
OPERATION PERMIT
' 'SYSTEM INSTALLED BY Ul
79 ,
Lit
AUTHORIZATION NO. OPERATION PERMIT B DATE: lit
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT 141=DESCILABOVE,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 ASA
• GUARANTEE THAT THE SYSTEM WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD:OF TIME.
- DCHD 05/96(Revised)
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od
4 9'_."'-5't t3 krstti:'F'k.+tr . l`a' `r •h'-�73 f. _! `. ',....:;,iJ .-_.. { ...: ' r:� ai i'-f`i �.,
CO NTY HEALTH DEPAR MENT
IMPROVEMENT AND OPERATION PERMITS, . PROPERTY INFORMATION
`.
Permittee'sj
Name:, t r Subdivision Name:
�:..
Directions to property: ' Section: Lot::
,,. IMPROVEMENT
} t Tax Office PIN:#
"�t.{ ti r. ✓ t. -.� (..r r. -1 �. PERMTT
Road Name. ' ^^.., Zip: .
**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
constructionlinstallation of a system or the issuance of a building permit.
(In compliance.with Article 1.1 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
-- 1 ,I ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRORMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE M 4 _ #BEDROOMS L#BATHS 2=#OCCUPANTS -2— GARBAGE DISPOSAL.Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
IoOX IS0 /
LOT SIZETYPE WATER SUPPLY ) i Y DESIGN WASTEWATER FLOW(GPD) NEW SITE ' REPAIR SITE' ✓
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH i ROCK DEPTHLINEAR FT.` PJ,
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: ' I Q LL p Go^YCOJ Q K�G� �, o�F `acp. I,,.i Zz:,
IMPROVEMENT PERMIT LAYOUT
*APPROVED EFFLUENT FILTER' *RISER(S) IF 6" BELOW FINISHED GRADE*
loo FSP. L,
wi
oF(- -i3au�
Pao. r) 'A_$(v'x-24 '
5�►Jt��-t% l l tic
: **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 THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760.
XXXXXXXXX
(336)751-8760
OPERATION PERMIT
SYSTEM INSTALLED BY: W LLI/�Ch�i L .L
&0 3L;'x,7q
J'�py� $ s•r
G /D�tom`
( ,
AUTHORIZATION NO 39q OPERATION PERMIT B DATE: //1
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE
THAT DESCRIB 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 EVAUTATiON/IMPROVEMENT PERMIT do ATC r 0 V i5
Davie County Health Department 1a-as
Environmental Hey IM Sectlon
P.O. Box 848/210 Hospital Street APR � ��
Mocksville, NC 27028
(336)751-8760
***nWCM "** %HIB APPLICATION CANNOT BE PROCZOSED UMSS ALL Tid RZQUIRaD
11MORMATION IS PROVIDED. Refer to the INID MATtCN BULLZTIH for instructions.
1. ltaae to be Skilled f-Jcn5 1AC-t-nF• Contact Person &54ror4 S4u'cs
Nailing Address
Cit?/stat*/stir V3, 2 10JS aminese ('pone 34157- (oq L3 �C�=
Z. wasu'on perait/ATC it Different than Above
Nailing Address Cit=/stat*/nip
e. Application for: 17 Site evaluation O Improvement Perslit/ATC [3�Oth
4. systen to services O House Home O Business O Industsy O Other
S. it Residence: t People f Bedrooms 3 t# Batbrooms 2-,
9-01shwasher O aarbege Disposal 81aahing(wahine 0 aas*a*nt/plumbing #] aassmant/No plumbing
6. 22 susiaees/Zadustry/Oth*ri ap*cify type i people f Sinks
/ Commodes ; showers i 'Urinals ftt*r Coolers
Ir fOODuRVICe: it Seats estimated Water Usage (gallons per day)
z. Type of water supply: 6-1county/City 11 Well 13 Community
9. Do you anticipate additions or expansions of the facWty this system Is intended to serve? a Yes qlqo--'�
If yes,what type?
***IMPORTANT***CLIENTS MU TCOMPtE1ETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN UMT BESVB1tiITI'ED by the client with THIS APPLICATION.
i
Property Dimensions: l CYO X 0n WRITE DIRECTIONS(from Mocksvllle)to PROPERTY:
Tai Office PIN: # _ ��.�— ( —,��0� !DO ( -> 4C) t > R O l Iy
Property Address: Road Name 2FDL- -A-�> AC, LZ�i CVA R(---'6L-AN b GO
CitylZip �i�TU��I� d2�-2� �•� f'kIL85 CC-Clf tt✓ t-T
If In a Subdivision provide Information,as follows:
Name:
Section: Block: Lot: Date Property Flagged: Ac),
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 Incamd from
this appUcadom I,bereby,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
to conduct sH kiting procedum as necessary to determine the site suitabW
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).
Site Revisit Charge
Date(s):
Lo I Client Notification Dates
63 .5-63 .5- 69 +3) EHS:
Account No.
Revised DCHD(07/99) Invoice No. �S'
MA`r'.23.2000 8:35AN NELSON BOYLES ATTY NO.925 P.2
Nw soN, BOy ,I;S,NIBLOCK & GRnEN
A77ORNEYS AND COUNSELORS AT LAW
101 CHARLPIS BOULEVARD,SUITE 102
WINSTON-SALEM,NORTH CAROLINA27103
WILLIAM L.NELSON
LAUREL O.BOYLES
M.DAVID NISLOCK TELEPHONE(336)760-9002
EDWARD R.GREEN FACSIMILE(336)70.9013
BILL I,LONG,JFL E-MAIL:nbng0triadlitrnet
CHARLES R EAKES
May 23, 2000
Subject property was conveyed to Bob L. Smith a/w Ada Smith by Deed recorded in Book1261,
Page 127 Forsyth County Registry in 1974. In 1985 subject property was conveyed to Arthur T.
Adams and wife,Ann M, Adams the current Owners.
MAY.23.2000 8:35AM NELSON BOYLES ATTY NO.925 P.3
EXHIBIT A
All that certain tract of land, lying and being in Farmingtoi
Township, Davie County, North Carolina, and being more particularly
described as follows:
..BEGINNING at a point, an iron nail in the edge of pavement'of
Gordon Drive (SN 1448) Laura Wood's Southwest corner, and designated as
point " S " on a survey prepared by Francis By Greene and Grady L.• Tutt.erow
on file in the proceedings entitled Bob L. Smith and wife, Ads Satith versu9
Laura S. Wood'a ( 82 'S? 138 ), Davie County Clerk of Superior Court's
Office, being the Southeast corner of the within tracts running thence as
per survey North i degree 57 minutes 59 oeconds East 102.04 feet to a
point, a granite monument said Wood's corner: thence, North 88 degrees 09
minutes 01 seconds Went 142.09 feet to a point, a 'granite monument in the
east edge of right of way of Radland Road ( SR 1442 ); thence, with said '
ltedlend Road* South 10 degrees 37 minutes 00 seconds mast 99 feet to a
point, an-iron stake in said right of way within the fight of way of Gordon
Drive-, thence, South 88 degrees 08 minutes 08 seconds Fast approximatall
150 fpet to the'BEGINMG, as appears from said plat above designated.
The Grantors herein intend to convey to the Grantee herein all rights
title and interest that they have in that real property described in a deed
dated April 90, 19859 and recorded in Deed Book 126, at pegs 5451 Davie
County, North Carolina l<egistry.