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4517 Hwy 64WHEALTH DEPARTMENT RELEASE d�„to Davie County Health Department r 210 Hospital Street P.O. Box 848. Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: James Bryan Rogers Address: 4517 US Hwy 64 W City: Mocksville State2ip: NC 27028 Phone # (704) 397-6252 For Office Use Only *CDP File Number 197909-1 ' County ID Number: Evaluated For. HDRNVWC PERMIT VALID 1 0 .1 7 / a 0 a'i 0 UNTIL r Property Owner: James Bryan Rogers Address: 4517 US Hwv 64 W City: State2ip: Mocksville NC 27028 Phone M (704) 397-6252 Property Locatlon & Site Information Address4517 US Hwy 64 West Subdivision: Phase: Road # Mocksville NC 27028 _ _ SINGLE FAMILY Township: 'Structure: Directions # of Bedrooms: 3 # of People: 'Water Supply: WA Basement: [:] Yes D No 'Proposed Improvement: Replacing Home Hwy 64 West, 1 Mile on right cross 1-40 Type of Business: Total sq. Footage: No. Of Employees: Home/dck must be moved to accomodate 25 foot setback to the well. Any portion of the home mut be 5 foot from septic Lot This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? OYes ©No Applicant/Legal Reps. Signature-, *Date: *Issued Bv' 2140 - Nations, Robert .f Authorized State Agent: *Date of Issue: 1 0/ 2 7./ 2 0 1 5 **Site Plan/Drawing attached.** �' bland Drawing 4lmport Drawing HEALTH DEPARTMENT RELEASE 197909 -1 Davie County Health Department CDP File Number. 210 Hospital Street P.O. Box 848 County File Number: Mocksville NC 27028 Date: 10 / a 7 / a 0 1< 5. Oinch Scale: O Block Drawing Type: Health Department Release ONIA rT l Plione: (336) - 753 - 6780 11 1 9 Davie County Health Department Environmental Health SectionC , P.O. Box 848 210 Hospital StreetCourier #: 09-40-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 Name: ffaMeS OMAA0&1 Phone Number ?Pq -397 &2SZ (Home) Mailing Address: yL15"Ln (&vw 33(p 7py8 %(pd (Work) Detailed Directions To Site: �'/�./�S%J• % ! �Z - %> !�l_SLt� F en T• A"(61 cr v t i b1-eT Property Address: Y47 IIF A�&y W r i- / 4rC-An-/GG & zyc- 2-,2,9 ' Please Fill In The Following Information A hout TheEXISTING Facility: 7�q �`/ T r^/ e Y V 1 Name System Installed Under: yr Of Facility: Date System Installed (Month/Date/Year): 2-00Number Of Bedrooms: .3 Number Of People:_ Is The Facility Currently Vacant? Yes a If Yes, For How Long? Any Known Problems? Yes a If Yes, Explain: s Please Fill In The Follrodcda g information About The NEW Facility: Type Of Facility: y Number Of Bedrooms: Number of People Pool Size: K Garage Size:— Other: Requested By: Date Requested: L S � R r For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$74U,,Q Z1 Date: Paid By: Received By: Account #:-I InvoiceIIAA'I'l FV- #: . ,�y a 9 44 -/ 4L 1-) Itv l �I S3� 1,01 /hal d ' DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 8481210 Hospital. Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 OPERATION PERMIT Account #: 990004259 Tax PIN/EH #: 4797-58-2998 Billed To: James Rogers Subdivision Info: Reference Name: Location/Address: 4529 US Highway 64 West -27028 Proposed Facifity: Residence Property Size: 2 Acres ATC Number: 4635 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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. System Type: S.T. Manufacturer 5 a Tank Date ]-;I:— Tank Size Pump Tank Size System Installed By:,A q � r r i I E.H. Specialist: ate: J 2 s 0 DCHD 11106 (Revised) 7 •a JAF�, r91=9 ..y R. � (� DAVIE COUNTY ENVIRONMENTAL HEALTH �(yl" P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004259 Tax PIN/EH #: 4797-58-2998 Billed To: James Rogers Subdivision Info: Reference Name: Location/Address: 4529 US Highway 64 West -27028 Proposed Facility: Residence_ Property Size: 2 Acres ATC Number: 4635 Site Type: 9`New ❑Repair ❑Expansion **NOTE** This Authorization to Constnict (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. Residential Specifications: #'Bedrooms # Bathrooms DL # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size Q — Type of Water Supply: ❑ County/City%2-Vrell ❑ Community Well System Specifications: Design Wastewater Flow. (GPD) -3 Coo Size_4,ac)cjGAL. Pump Tank W/T9GAL. Trench Width 3 & r Max. Trench Depth-�G " Rock Depth (;L Linear Ft. WC Site Modifications/Conditions/Other: 4w, stated in 1 SA N(`A(,% 18A,i96q(5) accepted Systems may also be used Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 - 9:30a.m. on the day of instaDlion. Telephone # (336)751-8760. 3 s AN: NGIiAAQi.# ✓ % eel % KJgCf-- 7,rG a",- Aoo, v 16 F."rf og/dlaer% dellW Environmental Health Sp Date: APPL ITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street ` Mocksville NC 27028 , (336)751=8760/ Fax (336)751=8786 Appl cation Fgr:- -stlill6n/Improv ment Permit ❑Authorization To Construct(ATC) ❑Both Type f Applic£Repair to Existing System ❑Expansion/Modification of Existing System or Facility ** 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't_S 0/2-, 6560—Contact Person Billing Address c(Soi4 }j�,vl, (v W C Home Phone City/State/ZIP M o UA S UZ R el - ✓UC 2 �O2- Business Phone Name on Permit/ATC if Different than Above, Mailing Address ' PROPERTY INFORMATION *Date House/Facility Corners Flagged Q?/Z /O `i 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 �,n, ,v f .1i1: cL,�, �� G'v�, �r1 (&d) Phone Number �rx1 ,7�'I 7-127 Owner's Address V5dy City/State/Zip ��� ti,. l (r d(- Z102,Y Property Address N3dh �� City Ott o dc5 �, (y Lot Size_ ,¢cam Tax PIN# el -117 -SK - 0 g� Subdivision Name(if applicable a Section/Lot# Directions To Site: S y '�b �� �;4 iia r tIvN r,:,G� , 3rr'f L►uyF o, • /i s 4 /- If the answer to any of the following questions is "yes", supporting documentation must be attached. A Note Sutier Are there any existing wastewater systems on the site? ❑Yes Eeo Does the site contain jurisdictional wetlands? Dyes o done,, there any easements or right-of-ways on the site? Aes o Is the site subject to approval by another public agency? Dyes C1,000 3 0 Will wastewater other than domestic sewage be generated? ❑Yes Cho IF RESIDENCE FILL OUT THE BOX BELOW # People `t. # Bedrooms 22 # Bathrooms Garden Tub/WhirlpooIXYes ❑No Basement: ❑Yes (XNo Basement Plumbing: Dyes Mo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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 system requested; /conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water aew Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? Res ❑ No If yes, what type? go% / /-[Uoo i) -kl& 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 M of the Davie County Health Department to conduct necessary inspection 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 flagging or staking the house/facility location, proposed well location and the location of any other amenities. Site Revisit Charge e s or s le epresentative signature Date(s): a -,2 Client Notification Date: Dae EHS: Sign given ❑Yes ESNo Account # ' Revised 11/06 Invoice # I � ly . I s ME (1 .84A , e 8130 Nv Ch V3-10 2998 S 1 .67A), 691 j o X53} cv a_ y , . 1 APPLICANT INFORMATION Account #: 990004259 Billed To: James Rogers Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 4797-58-2998 •i Subdivision Info: Location/Address: 4529 US Highway 64 West -27028 Property Size: 2 Acres Date Evaluated: E Water Supply: On -Site Well ommunityPublic Evaluation By: Auger Boring Pit Cut FACTORS 1 2 43 ' 4 5 6 7 Landscape position tn�rlte5 - Slope % ^� , HORIZON I DEPTH Texture groupY L Consistence ' Structure `► �o�;t r' mat,,, Mineralogy HORIZON II DEPTH Texture group Ci Consistence �• Structure k, Mineralogy1 + 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 10 + SITE CLASSIFICATION: cw +�i3-Vh� EVALUATION BY: ({fie Ili ✓(/���' LONG-TERM ACCEPTANCE RATE: - OTHER(S) PRESENT: REMARKS: LEGEND- Landscape EGEND- I, n s ape 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 $I - Silt SICL - Silty clay loam SIL - Silty loam' CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay, C Clay; CONSISTENCE MWA 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 t 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 )yste� 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 05105 (Revised) ■■■see■■■c■■e■c■■■■cc■■■ec■■■e■■■■■■■■■■■■■■■■■tcc■■e■■■■■■■■■■■cce■■■■■■■c■■ee■■■a■ ■■■c■■■■■■■■■■■■■■■■cee■■■e■■■■■■■■■e■■■■c■eac■■eee■■ec■■■■■■■■■■■eee■■■■■e■■■■■■■■■ ■■c■■ceccec■■■■■■■■■■■■■■eec■eec■■■c■■■■■e■c■■■eee■■ee■■■■■■■■■■■eic■■■■eee■■■■■■■■■ ■■■■■■■■c■■■■■■■■■■■■■■■■■c■■■■■■■■c■■■c■�■s■■■c■■■■■■■ea■■■■ec■■c■■■■se■■■■■recce■ ■■■■■■■■■■■■■■■c■■■eee■■■■■■■■■■■■■■■ec■■■■■s■■■■■■■■■■■■■■eec■■e■■■■■■■■■■■■■■■■■■■ ■■■■eee■■e■■■■■■■■■c■■■■■■c■■■■ciccc■■■ic■■■■■e■■■e■eee■■c■■■■cec■■■■eee■c■ee■eeec■■ ■■■■■■eee■■■■■c■■■■■■■■■■■■c■■■■■■■c■■■■■■■■■■■cec■e■■■■cc■■■■■■■■■■■■■■e■■■■c■■■■■■ ■■ccc■■■■■■■■■■ccc■■eee■■■■■■■■■■■■■cc■■■■■c■c■■■tc■■■■■■■eee■cccecec■■■■■ec■■■■■■c■ ■■■■■eiei■■■■■■s■■■cc■■■■e■■■ec■■eecc■■■e■■■■ees■eee■■eecee■■■■es■■■■■e■■■■■c■■e■cc■ ■■■■cccc■■■■ec■■■cc■■■eccc■■■c■■■e■■■■ce■ ■ccc■■■■c■■■c■■■■recce■eec■■■■■■■cc■■■■■■ ■■c■■■■■■eee■■■■c■■■■■c■■■■■■■■ccc■ecc■■■�i■■■■■■cc■eee■■■ec■■■■■■■■■■■■■cc■■■eee■■■ ■c■■eeecc■■■■■■■■■cecc■eee■■■■■■■■■■■■cccc■■■■ec■■ee■■■■■■■■■■■cc■■■ecce■■■■■c■■■■■■ ■■■■■e■■ccc■■■■■■■■■c■■ceec■■■■cc■■i■■■cccc■■■■■sceec■■■ec■■■■eee■■c■■es■e■■■■■■c■■■ ■■c■■■■c■■■■■■■■■ececc■■■■■■■c■■■cec■eee■■■■■■c■■■■c■■■■■■■■cec■■■■■■■■e■■■■ce■cc■■■ ■■■■■■■■■c■■■■■c■■■eee■■■■■■■■■■■■■ec■■e■�i■■■■c■■■c■■■cec■■ceccc■■■■■■■■■■■e■■■c■■■ ■■■■■■■■■c■■■■c■■■■■■■■■ecce■■■■■■cc■■cc■s■■■■■e■■■■cec■■■■ec■■■■■cc■■ce■e■■ce■■■s■■ ■■■■■c■■■■■■■■■■■c■■■■eec■■■■■■■t■■■■ce■s■■■■■■eee■■■■■■■ee■■■■cec■c■s■■■■■■■■e■eec■ ■■�•■�■■■■■■c■■■■■e■■■■■■■■■cc■e■■ecce■■n■■■■■■■ccc■■ecece■■■■■ccc■■■■■eec■■■ecce■■■ ■■■•■■■■■■e■■eae��■■ec■s■■■■■■e■■■■■■■cenc■■eccc■■■c■■■c■■■see■■■■■■cec■■■■■■■■■■■e■ MENNE MOMMiiiiiNEN MENNEN iiiiii iiiiii�iii ■■c��■■■■■■■■■■■��■►�r.�■■■■A�■cc■•__c�c■e■�i■■■■■cs■■recce■■c■e■cc■■■■se■■■s■e■cc■■ee■■ ■■s.■e■■cc■■■■■■`aac���■■■�=J■■■■■;•�■■■■■i■■■c■■■■■■■■■■■■■e■■■■ere■■■■■■■■■■■■c■■■■■ ■■■■-c■■■■■■■■■■c■c�■r,■■■■■■■ece■e�e■■ee�cs■■■e■■■■s■■■ec■■exec■■■■■■■■■■■ees■■■■ce■ e■ec.e■■ec■■■■■■■■■■■ie■cec■■c■■■■c■■■ec■■■■ei■cceece■■c■■■ecc■■ecce■■e■■cc■■■■ec■■■■ ee■■■�:_:�_••■ecce■■■��c:�■■■■■■■cc■■■■c■■■■■■■■■■c■■aces■ec■■■■ce■■■■■e■■■■■■ce■■■ec■ ■■■■c■■ec��e■_■■■■.■■■i�e�ee■■■■■■■■e■■■■■■■■■■cce■■ee■■■■■■■■■■■■■eee■■■■ee■■■■■e■■■■ ■■■�t■■■■ec■■■e■■■■■■■■c■c■eec■■c:::�:�•••� ■■e■■■ce■■■e■■■■■■■■■c■■■■■■ccs■e■ec■■■■■ ■e���■■■■■■■■■ee■■■■cc■■■■■■■■■■■■■■■cecec■■■■■■■■■■■■■■■■■■■e■■■ere■■■■■■■■■■■ccc■■ ■■■�■c■eee■■■c■■■■■■■■c■■■■■e■■■e■■■■■■■■■■■■■s■■■c■■■■■e■■■■■■■■■■■■c■■■ee■■■■■■■■■ ■■■■■■c■■sae■■sc■■■■■■■■■■■■■■■■■■ec■■■■■�■■■■■■■■■■■e■■■■e■■■■■■■■■■■■c■s■cc■■■■■■ ■■■■■ecc■cc■■■c■■■■■■■■c■■■■■■■■e■■see■■■■■■c■■■■■■■■■■c■■■■■■■■■■■■■■■■e■■■■■■■■■i Account #: 990004259 . Billed To: James Rogers Address: 4529 US HWY 64 West City: Mocksville Reference Name: Proposed Facility: Residence IMPROVEMENT PERMIT Tax PIN/EH #: 4797-58-2998 ' Subdivision Info: ` Location/Address: 4529 US Highway 64 West -27028 Property Size: 2 Acres **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 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: l<ew ❑Repair ❑Expansion Permit Valid for: P 'Tears ❑No Expiration Residential Specifications: # Bedrooms 3 # Bathrooms # People Basement❑ Basement plumbing❑ Non -Residential Specifications: FacilityType # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 3 6c) Type of Water Supply: RCounty/City ell ❑Community Well As stated in 15A NCAC 18A.1969(5) Site Modifications/Pemzit Conditions: Accepted Svstems may also hes used System Type LTAR Initial d-. Repair d - Environmental Health Specialist i.p. 11-06 v q Parcel #: J10000001202 Davie County, NC - Basic Estate Search Basic Search Real Estate Search Tax Bill Search Sales Search View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information Parcel #: 310000001202 Account #:82528004 Owner Information 32,08 000111 Tax Codes 1,49 OGERS JAMES BRYAN& KILLMEYER SAMANTHA 24,47 ADVLTAX - COUNTY TA 58 04 517 HWY 64 WEST 58,04 READVLTAX - FIRE TAX OCKSVILLE NC 27028 Property Information Township Land (Units/Type): 1.790 AC CALAHALN ddress: 4517 W US HWY 64 Deed Information Local Zoning Pate: 04/2007 Book: 00710 Page: 0586 Plat Book: 0009 Page: 107 Legal Description PIN LOT 3 1.787AC ROGERS S D 4797593111 Property Values uildin : 32,08 000111 BXF: 1,49 nd: 24,47 Market: 58 04 ssessed: 58,04 Deferred: Sales Information No. Book Page Month Year Instrument Qual/UnQual Improved Price L 00089 0171 03 1973 WD Unqualified Vacant 0 i 00710 0586 04 2007 WD Unqualified Vacant 0 View Property Record for this Parcel View Map for this Parcel View Tax Bill Information « Return to Basic Search Page 1 of 1 wrjl-11� 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/itsneWiew.asox?prid=1466490 7/12/2016