2757 Hwy 64E _ - .
. ,, ' ` DAVIE COUNTY HEALTH DEPARTMENT
• T� • Environmental Health Section ,
�. P.O.Boa 848/210 Hospital Street
' Mceksville,NC 27028
(336)751-8760
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Account #: 990004025 Tax PIN/EH#: 5767-69-8453
� � Billed To: Brian Moore Subdivision Info:
� Reference Name: Location/Address: 64 E-27028 o27J�7
,Proposed Facility: Residence Property Size: 3.23 acres
ATC Number: 4451
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 Fonn/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 WASTEW S Td FOR RIOD OF FIVE ARS.
Environmental Health Specialist's Signa ate: �U �
CERTIFICATE OF COMPLETION
**NOTE** The issuance ofthis Certificate ofCampletion shall indicate the system described on ImprovemendOperation 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 tune.
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Septic System Installed By: �
Environmental Health SpecialisYs Signa / �L �
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DC�ID OS/99(Revised)
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. ' DAVIE COUNTY HEALTH DEPARTMENT
,, Environmental Health Section ��
' . P.O.Boz 848/210 Hospital Street
• • Mocksville,NC 27028
� � '. (336)751-87G0 �//Z D �
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IMPROVEMENT/OPERATION PERMIT
Account #: 990004025 • Tax PIN/EH#: 5767-69-8453
, Billed To: Brian Moore Subdivision Info:
Reference Name: - Location/Address: 64 E-27028
Proposed Facility: Residence � Property Size: 3.23 acres
ATC Number: 4451
**NOTE**This ImprovementlOperation 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,Wasfewater Systems,Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR TI�INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type N�I�J� #People .Z #Bedrooms�_ #Baths 2-
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 3•23��T�pe Water Supply��DtN1�YDesign Wastewater Flow(GPD) � Site: New I.� Repair❑
System Specifications: Tank Size��AL. Pump Tank GAL. Trench Width 3fo�� Rock Depth� Linear Ft. 1�Cj
Other: �����'� .2�,Lb I��,IZ',Tlc�i.1 �ST�M,3 a}�T����o� �,�
Required Site Modifications/Conditions: ���T�l-�- C�-' C�-�i�c92 kL=�-`n � [�F ���=-
IMPROVEMENT/OPERATiON PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6`�BELOW
FINISHED GRADE. ****NOTtCE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system betwoen 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.****
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' �t.'���� Mocksville, NC 27028 �-�
Phone: (336)-753-6780 Pax:(336) -753-1680
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ON-SITE WASTEWATER CERTIFICATION FOR DWELLTN.G
(Check One) Replacement Remodeling Reconnection �' - _
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�Name:��r, r�� /��"����J�^�2 Phone Number II'S " �l � � (Home)
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MailingAddress:�7 � !�' � � �` `j��' �-/�j '" 4/��)�� (Work)
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Detailed Directions To Site:
Property Address: � � �
Please Fill In The Following Informatiori About The EXISTING Facility: �
Name System Installed Under: Type Of Facility:�J,�,S�'
Date System Installed(Month/Date7Year): ����J Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Ye No If Yes,For How Long? �
Any Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
T e Of Facili � P�(9'f���� �/�
yp ty;^ �� T.T,,mhP�nfRA.�r^,�;=;:��Number ofPeople
�Requested By: � � �-:�- Date Requested: � —_� '� f�
� ignature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date: l�
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be�taken as a guarantee
(extended or limite )that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Chec Money Order # �G' Amount:$ /UCj.(1 Date: � "��
Paid By: ' �,.��1017�% Received By:
Account#: �(}Z� Invoice#: ���/ ,
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. APPLICATION FOR SITE EVALUATION/IMPROVEME �'T-�
, . Davie County Health Department �
JUN 2 9 2006
Environmental Health Section 1�
� P.O. Box 848/210 Hospital'Street i
, ' Mocksville,NC :27028 E�wiRONh�ENTnL H�LiH
DAVIE COUNTY
(336)751=8760/'Fax(33�751`-8786` .
Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) l�'Both
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION �
Name to be Billed �r��n �- F � I�� M ��,_Contact Person 6 r �O�r, N1�b C?r�P�
Billing Address 2 VV�i � Home Phone 3 3� -9 q g"- �-3(o O
City/State/ZIP�� k�v-j ( �,2, C Z-7 � Z�Business Phone 3�(o -�7 51�--ZCo 2'7
Name on PermidATC if Different than Above
Mailing Address City/State/Zip �
PROPERTY INFORMATION
NOTE: A survey'plat or site plan must accompany this application.
(Pernut is valid for 60 months with site plan,no expiration with complete plat.) S7 L 7-b q-�4�53
Street Address r� �o�, City M�.ks v� 111, Tax PIN#J'�lOOOO��(ol y
Subdivision Name n�o� Section/Lot# r I Ch. Lot Size � � 2 3 /�G
Directions To Site: ArCrp�S -f�rOrr 2"7 `'1 8 1-�-wu (p�-/ � a.S -f'� N1aC-ti��/'�11�2�
1
Date House/Facility Corners Flagged (a /2$ O[�
If the answer to any of the following questions is"yes",supporting documentarion must be attached.
Are there any existing wastewater systems on the site? ❑Yes C�33�o ,
Does the site contain jurisdictional wetlands? ❑Yes CC�2�
Are there any easements or right-of-ways on the site? ❑Yes L�o
Is the site subject to approval by another public agency? ❑Yes B3�
Will wastewater other than domestic sewage be generated? ❑Yes �o
IF RESIDENCE FILL OUT THE BOX BELOW
#People Z #Bedrooms �� #Bathrooms �. Garden Tub/Whirlpool � ❑No
_ Basement: ❑Yes C+�2�o Basement Plumbing: ❑Yes Ci�o
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type systemrequested: 6kConventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: G�C,ounty/City Water ❑New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes C�'No
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any pernut(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 understand that I am responsible for all charges incurred
from this application. 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 laws and rules on the above described property located in
Davie County and owned by �1"1 O..Y1 ''MO C�`r�
Site Revisit Charge
roperty owner's or owner's legal representative signature
Date(s):
� I Z g / �� Client Norification Date:
Date EHS:
Sign given ❑Yes ❑No Account# �D Z-r
Revised 2/06 Invoice#
� �� i '' � ; DAVIF. COUNIY HLALTIiDLI'ARTM.CNf,
• Environmental Health Section
, . � Soil/Site Evaluation ,
APPI,ICANT INFORMATION PROPERTY INFORMATION
Account #: 990004025 Tax PIN/EH#: 5767-69-8453
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�illed t�: , Brian Moore Subdivision Info:
Reference Name: Location/Address 64 E-27028 �
Proposed Facility:� Residence Property Size: 3.23 acres Date Evaluated;
Water Supply: On-Site Well Community Public ' y��
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition j... S L
Slo e% �
HORIZON I DEPTH s Q- , :
Texture rou �a c. 5 (r-
Consistence S ��S �
Swcture
Mineralo N�
. HORIZON II DEPTH �p -2. -
Texture rou -jL� SGtr
Consistence ., F.` SS ,
Swcture _
Mineralo . �(
HORIZON III DEPTH Z(o ' '
Texture rou �i
Consistence
Swcture .
Mineralo �
HORIZON IV DEPTH
Texture rou � +
Consistence
Structure
Mineralo
SOIL WETNESS _
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: � EVALUATION BY: �
�_ —�- \
LONG-TERM ACCEPTANCE RATE: �' � OTHER(S)PRESENT: ��t-�`'` ' � "�
REMARKS: _,��70X ���tS X,rt (���tt �'
LEGEND �
I�andscapc 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
_ Txu
S-Sand . LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay]oam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
` CONSIST�NCE
Mvist
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely Crm
.Wet
� NS-Non sticky SS-Slighdy sticky S-Sticky , VS-Very Sticky
� NP-Non plastic SP-Slightly plastic P-Plastic VP-Vcry plastic
r c r
�SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic .
Mineraloev
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 OS/99(Reviscd)
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� � Davie County Health Department
Environmental Health Section `
- P.O.Box 848/210 Hospital Street
� Mocksville,NC 27028
_ (33�751-8760/'Fax(336)751-8786
Improvement Permit
Brian and Emily Moore
2429 Milling Road
Mocksville,NC 27028 �
Re: 3.23 Acre Tract/Highway 64E
Tax PIN#5767698453
Dear Client(s):
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 pernut(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Pernut is subject to revocation if
site plans or the intended use change.
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System To Serve: ` (.�Wastewater Design Flow(GPD): �.7 Valid: Years ❑No Expiration
System Type: �Conventional C�ccepted ❑Innovative ❑Alternative ❑Other
Site Modifications/Permit Condirions: �
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Parcel#: J70000006104 Page 1 of 1
o��t�
Davie County, NC - Basic Estate Search �ov��
` Davie County Web Site
Basic Search Real Estate Search Tax Bill Search Sales Search Q�
View_Pro�ertv Record tor this Parcel View Ma�for this Parcel Vlew Tax Bill Information
Parcel#:J70000006104 Account#:82526827
Owner Information Tax Codes
MOORE BRIAN M&MOORE EMILY ADVLTAX-COUNTY TA
757 US HWY 64 EAST FIREADVLTAX-FlRE TAX
MOCKSVILLE NC 27028
Pro e Information Townshi
Wnd(Units/Type): 3.230 AC FULTON
ddress: 2757 E US HWY 64
Deed Information Local 2onin
Date: 08/2006 Book: 00675 Page: 0639
Plat Book: Pa e:
Le al Descri tion PIN
.500 AC HWY 64 5767698453
Pro e Values '
Buildin : 220 63
BXF:
Land• 38 28
Market: 258 91
ssessed: 258 91
Deferred•
Sales Information
No. Book Page Month Year instrument Qual/UnQual Improved Price
00514 0035"09 2003 WD Unquaiified Vacant 0
00675 0639 08 2006 WD Unqualified Vacant 0
00522 0970 11 2003 WD ualified Vacant 27 500
View Prooertv Record for this Parcel View Ma�for this Parcei View Tax Bill Information
« Return to Basic Search '
Ali information on this site is prepared for the inventory of real property found wlthin 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 Devie 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 inerchanYability 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.daviecountyna�ov/itsnet/View.aspx?prid=1458121 6/29/2016