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199 Jesse King RdAccount #: 990004382 Billed To: Rick Stutts Reference Name: Proposed Facility: Residence ATC Number: 4782 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax #(336)751-8786 OPERATION PERMIT Tax PIN/EH #: 5863-36-8292 Subdivision Info: Location/Address: Jesse King Road -27006 Property Size: .79 acres **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: -44— S.T. Manufacturer $ 6f Tank Date l' '""_'Tank Size Yy1 Pump Tank Sized! System Installed By:JrGt.J!! 1 E.H. Specialist: Date: S'1 -o Y DCHD 11/06 (Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990004382 Tax PIN/EH #: 5863-36-8292 Billed To: Rick Stutts Subdivision Info: Reference Name: Location/Address: Jesse King Road -27006 Proposed Facility: Residence Property Size: .79 acres ATC Number: 4782 Site Type:,9<ew ❑Repair ❑Expansion **NOTE** This Authorization to Construct (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 O;Z # Bathrooms 7— # People Basement❑ Basement plumbing❑ Non:Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size 7q t�g Type of Water Supply unty/City ❑Well ❑CommunityWell System Specifications: Design Wastewater Flow (GPD) 2 crank SizeT7GT7�ii 'AL. Pump Tank GAL. -OC6 Trench Width, Max. Trench Depth '�Rock Depth I -C' Linear Ft. lLc t-�a,2s,� 0 Site Modifications/Conditions/Other: h: r © 1: F t -'t \ _ Contact the Davie Cou 8:30 _ 9 jEnvironineiiial Health Section for final in i.m. on the da of installation. TeIevMne' 'mss 1C� � � iG 1 Z' f �,-Na►'J.lf1 9+ v �i alzo As strited in 15A NCAC i£1A.1989(S) ac epted Systems may also be used Environmental Health Specialist DCHD 11106 (Revised) a e 4S i of this system between '51-8760. 3co- 1 �-a I Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 990004382 Tax PIN/EH M 5863-36-8292 Billed To: Rick Stutts Subdivision Info: Address: 224 Jesse King Road Location/Address: Jesse King Road -27006 City: Advance Property Size: .79 acres Reference Name: Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization To Construct a was 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: Aew ❑Repair ❑Expansion Permit Valid for:,B Years ❑No Expiration Residential Specifications: # Bedrooms ;?— # Bathrooms -)— # People Basement❑ Basement plumbing Non -Residential. Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 9AV Type of Water Supply: ;�eounty/City ❑Well ❑Community Well Site Modificatioins/Permit Conditions.: System Type LTAR Initial Plan 1-7H 1 6 14LO TZJ=P/-N-% Environmental Health Speci ix.l l -06 Z12' Date_ li 9'07 0 v 1 0)h ;X N24'01'22 E \R 168:29' NEW LINE CIV0 X co G40 Owp�. a., X G' �A P 30 � 9�1 ` P ��Ggti 0'I90 0� $OL p�4 �6 W ( 306 'SzG 26� ^M 66 ti6G2 P\N� N o '` G0� �Er1 0 o cti i � � I 0 505 Q 2 i •` � 6�6 ;�0� �Ft , X / N 65 x '15 ( -179 it -k Q4i� Frzo e -r-1 o� .�eS5c� goo�� t7f3 � qa e 1427P `� d dBZ:tO LO L L Inf OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 P�HFA (336)751-8760/ Fax (336)751-8786 ppli 0�Ci1'�� aluation/Improvement Permit ❑ Authorization To Construct(ATC) oth e of 1�pp ion: ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions: APPLICANT INFORMATION Name to be Billed RIJ 011- 1, Contact Person . � gulh Billing Address 22U �T- ��/i r, 4 � Home Phone �$- City/State/ZIP � Q t/, r41 1«_ AJC- 1 rhV e M Business Phone U627-33,00 Name on Permit/ATC if Different than Above Mailing Address PROPERTY INFORMATION *Date House/Facility Corners Flagged 3 07 NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan �lat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name el 5L4f Phone Number -11 W= y269 Owner's Address 2 City/State/Zip c"Ue'«G p Or 2706K Property Address City vg v�� �T Lot Size ,7q Ctc, Tax # �M-936Vg2 Subdivision Name(if applicable) Section/Lot# Directions To Site: --I, yd t - -h, go/ Axl ort SDI Q� 2� n �i rr w o /L. 2 in;. P,. + n,,.`To,.o Lam,-.,.. 124 Z1 in 44�s�- If the answer to any 6f the following questions is "yds % supportiig documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes UK'o­ Does the site contain jurisdictional wetlands? [I Yes 090 Are there any easements or right-of-ways on the site? ❑Yes 9N'o� Is the site subject to approval by another public agency? ❑Yes 21qr h Will wastewater other than domestic sewaGe be Generated? ❑Yes Colo IF RESIDENCE FILL OUT THE BOX BELOW # People I— # Bedrooms 2 # Bathrooms * - 2 Garden Tub/Whirlpool ❑Yes ❑K -o Basement: ❑Yes Edo Basement Plumbing: ❑Yes Certo 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; 06onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: VCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes or 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 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. % r Segirepresentative Site Revisit Charge,Pr p4erty owner's or ownersignature . Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # AP%j6ANT..I19 M ON Billed To: Rick Stutts Reference Name: Proposed Facility: Residence Water Supply: On -Site Well DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section , Soil / Site Evaluation Tax PIN/EH #: 5863-UNRTY INFORMATION Subdivision Info: Location/Address: Jesse King Road -27 06 Property Size: .79 acres Date Evaluated: Community Evaluation By: Auger Boring Pit Public +� Cut ff • • �=©��= �0® -_ - Landscape position HORIZON I DEPTH Texture group Consistence HORIZON Ui�r!W/_7i 0 S'z7 . _J[ VJIR-A -.• .r•����r�®sem Consistence W�MM�Wrmff.�r2i4Mf�Ar ���■� Structurel��L����-:1-- HORIZON -III DEPTH Texture group ConsistenceMineralogy If /�WIGS�-���r'a`♦��{��ll ��-- WIM, 10 -VE . • . • c.����■�r�� = ss • grTexture oup Consistence il��s�■������o� SOIL WETNESS CLASSIFICATION ff .. SITE CLASSIFICATION: 1 S EVALUATION B : LONG-TERM ACCEPTANCE RATE: -7OTHER(S) PRESENT. REMARKS: ►�k3. �1 b� ��-� 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 Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm I'YeI NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic 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 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) ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ iMEMNON iuiiiEAiiiNON MEiiiiiMENNENiiiiii ■■■■■■■■■■■■■■■■■■■■■■■■■/■■■■■■Ire!■/�■■■G :'}1:7■■■11■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■II■■■■■■■■■■fir:!t■ii1~li�■■■11■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■II■■■■■■■■■■■■■■■■■X191■■■■■■■■■■■■■■■I■■■■■■■■■■■■■■■ GoMAPS - Davie County NC Public Access 1 STUTTS Page 1 of 2 611 Wednesday, June 27 2007 http://maps.co.davie.nc.us/GoMaps/map/print.cfin?CFID=4129&CFTOKEN=61640881 6/27/2007 NOTES: 1. RAI/ ERROR OF CLOSURE 1:10,000+, LASCIOSURE WAS DISTRIBUTED BY COMPASS RULE. 2. AREA DETERMINED BY COORDINATE COMPUTATIONS. 3. DASHED LINES REPRESENT INFORMATION TAKEN FROM DEED OR PLAT. 4. DISTANCES SHOWN ARE HORIZONTAL GROUND DISTANCES UNLESS NOTED OTHERWISE. 5. PROPERTY ZONED - RA. 6. PROPERTY IS WITHIN A "11S -IV" WATERSHED ARF REFERENCES: 1. ALL DEEDS AND PLATS AS SHOWN. i SURVEYOR CERTIFICATION FON SUF`W1910N DAVIE COUNTT. NCNTN CAROLINA L CLDITON B. OSSORNE, PROFVW,T NAL LAND SURVEYOR, NUMBER L-3534 CERTIFY TO ONE OR MORE OF THE FOUDWLNC AS INDICATED BY AN R: I( A THAT THIS PLAT 13 CT A SURVEY THAT CREATES A SUBDIVISION OF LAND WITHIN AN AREA CF COUNTY OR MUNICIPALITY THAT HAS AN ORDINANCE THAT REF ruTES PARCELS OF LAND; _ B. THAT THIS PLAT IS O" A SURVEY THAT IS LOCATED IN SUCH PORTION OF A COUNTY OR MUNIC' AlXrY THAT IS UNREGULATED AS 70 AN ORDINANCE THAT FS,i';IATES PARCELS OF LAND: C. THAT THIS THAT IS G:' 1 SURVEY OF AN EXISTING PARCEL OR PARCELS OF LAND; D. THAT THIS PLAT IS OY A SURVEY OF ANOTHER CATEGORY, SUCH AS THE RECOMBINATION OF KISTI IC PARCELS, A COURT-ORDERED SURVEY, OR OTHER EXCEPTION Tr! THE DEFINITION OF A SUBDIVISION: _ E. THAT THE INFORMATION AVAILABLE TO THIS SURVEYOR IS SUCH THAT I AM UNABLE TO MA)- A DETERMINATION TO THIS BEST OF MY PROFESSIONAL ABM:. AS TO PROVISIONS CONTAINED IN A THROUGH D. ABO SIGNATURE '' - 3�3* SURVEYOR REGISTRATION NUMBER VICINITY MAP NOT TO SCALE / v / 0 Ir 4- led / / FRANK M. THARPE JR DB 426 PG 166 / TAX MAP 8-6 LOT 2602 (MORE THAN 10 ACRES REMAIN) r � JESSE KING RD. SR 1454 45' PUBLIC R/W BASED ON FOUND NCDOT R/W MONUMENTAnON X EDGE OF pAvn.r.. IRS P, -,se -:2 a BASIS OF BEARING NC GRID (NAD83) Certificate of oenerwhip end dedfenll— I (we) hereby certify that 1 wea ( ) the -(s) of the property deecrlbed hereon. which i. located in the vubdviam juri.M.tion of Dam County and that I hereby adopt this aobdivlaton plan with my hae ant. eA bli.b.d mlarmum building ..0 -Ir tin.. and dedicate an .t e.b ere;" an.:' walb. erk..na *the, �—dto public r pd.ale mea the, SO DataOwner(a) Frapk M. Tharp.. h. Ravinw Offlcot'. C -UD.. . /t /t &-"•! IYe"�. Review OHte.r of Devi. C.—ty certify that the map or plot to which this certific.u.. i. attached cease all statutory requirement. for recording. _ Review Officer Data CONTROL CORNER REBAR a?9, -,21 e �(0fly4 4 IRS !x Ro d 6 Q yRa 6^. x GRANII O ONUMENT CONTROL CORNER NEW 0.790 ACRE (34,438 SQ. F.T) OUT PARCEL /�� WITH 1,368 SQ. FT. IN„rR 40 FRANK M. THARP DB 426 PG 166Pfy A.G. PARKER TAX MAP 9-6 LOT/260z� IRSSN seWV No_Debi-- 02ra4 59' µ^ 61.70' PS 08 640 PG 951 TRACT 1 OF PB 8 PG 239 TAX MAP 9-6 LOT 2603 h� z� 3r ! Jqa N: 836,169.56' GRID E: 1,564,060.81' GRID - CONTROL CORNER GRAPHIC SCALE w d zo 40 fro leo ( IN FEET) . 1 inch = 40 ft. Negi.t.r of Deed. filing atatement n Filed RegieAI`on at JWO'elock Ia M. /g� 'i6ygi�7d recorded ie Flat Book Page D STANT - Dene Comity R.gi.ter o1 Deade No A vel Required by Davie County Planning Department _ 530 7' le Pmuag Di—to,Det \ J•�A t � LAIM yn(� 4qD- .4 r # /II1111tNAIAtOtI CERTIFICATE OF ACCURACY OF MAPPING 1, CLUMN B. OSBORNE. CERTIFY THAT THIS PLAT WAS DRAWN UNDER MY SUPERVISION FROM AN ACTUAL SURVEY MADE UNDER MY SUPERVISION (DEED DESCRIPTION RECORDED IN DEED BOOK 426, PAGE 166); THAT THE BOUNDARIES NOT SURVEYED ARE SHOWN AS BROKEN LINES PLOTTED FROM INFORMATION FOUND IN DEEDS AS LISTED; THAT THE RATIO OF PRECISION AS CALCULATED IS - 1:10,000+; THAT THIS MAP WAS PREPARED IN ACCORDANCE WITH G.S. 47-30 AS AMENDED. WITNESS MY HAND AND OFFICIAL SEAL T}BS�_ DAY OF MRF t.. 209. L-3834 __ LICENSE NO. PROFESSIONAL LAND SURVEYOR FINAT PIA'r 0.790 ACRE OUT PARCEL FRANK M. THARPE PROPERTY TAX 1(A.P B-6 LOT 2602 Owner: FRANK M. THARPE, JR. 301 BAMBOO LANE ADVANCE, NC 27006 Deed Book 426 Poge 166 Allied Associates, P -A. 4720 KeslerMRI Road Plane (336) 765-2377 Winston-Salem, N.C. 27103 FA% 760-9686 .-mail- AS.—yepol.com TOWNSHIP COUNTY STATE DATE Farmington Davie North Carolina 4/04/07 SURVEYED MAPPED: JOB NO. MAP NO. TDS CBO PA070327 MrC.OWG MTC ® Allied Assoc., P.A. 2007 NAIL 25' JiHIANNE 0. HANESDB / 85.52' NA''., ` L R\ 1B LEGEND TAX MAP 7GLOT74905 OMAR R. GRADEY - — DB 200 PG 229. EXISTING IRON PIN 0 EIP TAX MAP B-7 LOT 4901 EXISTING REBAR 0 REBAR EXISTING RR SPIKE O RRS WATER VALVE a WV' NO POINT SET • NPS UTILITY POLE .0' Iv IRON REBAR SET NAIL SET N IRS TELEPHONE PEDESTAL�y`V J - MAG NO POINT SET • MN X WATER METER 19 h A CONCRETE R/W MONUMENT A WELL O y"l nrO h� _ CILBOUNDARY LINE RIGHT-OF-CENTERLINWAY R/W RIGHT-OF-WAY LINE "1� CONCRETE MONUMENT C UNSURVEYED PROPERTY LINE CHORD CH FENCE LINE x - RAUIUS RAD .SE EG EDGE OF GRAVEL SIGHT EASEMENT DEED BOOK OB EDGE OF PAVEMENT PLAT BOOK - PB EASEMENT — — — NCGS MONUMENT ACRES AC - "VALLEY AZ MK" SOUARE FEET 50. FT N: 834,444.1283' ,"ARID RAILROAD _ RR E: 1,567,531.2842 GRID 08 640 PG 951 TRACT 1 OF PB 8 PG 239 TAX MAP 9-6 LOT 2603 h� z� 3r ! Jqa N: 836,169.56' GRID E: 1,564,060.81' GRID - CONTROL CORNER GRAPHIC SCALE w d zo 40 fro leo ( IN FEET) . 1 inch = 40 ft. Negi.t.r of Deed. filing atatement n Filed RegieAI`on at JWO'elock Ia M. /g� 'i6ygi�7d recorded ie Flat Book Page D STANT - Dene Comity R.gi.ter o1 Deade No A vel Required by Davie County Planning Department _ 530 7' le Pmuag Di—to,Det \ J•�A t � LAIM yn(� 4qD- .4 r # /II1111tNAIAtOtI CERTIFICATE OF ACCURACY OF MAPPING 1, CLUMN B. OSBORNE. CERTIFY THAT THIS PLAT WAS DRAWN UNDER MY SUPERVISION FROM AN ACTUAL SURVEY MADE UNDER MY SUPERVISION (DEED DESCRIPTION RECORDED IN DEED BOOK 426, PAGE 166); THAT THE BOUNDARIES NOT SURVEYED ARE SHOWN AS BROKEN LINES PLOTTED FROM INFORMATION FOUND IN DEEDS AS LISTED; THAT THE RATIO OF PRECISION AS CALCULATED IS - 1:10,000+; THAT THIS MAP WAS PREPARED IN ACCORDANCE WITH G.S. 47-30 AS AMENDED. WITNESS MY HAND AND OFFICIAL SEAL T}BS�_ DAY OF MRF t.. 209. L-3834 __ LICENSE NO. PROFESSIONAL LAND SURVEYOR FINAT PIA'r 0.790 ACRE OUT PARCEL FRANK M. THARPE PROPERTY TAX 1(A.P B-6 LOT 2602 Owner: FRANK M. THARPE, JR. 301 BAMBOO LANE ADVANCE, NC 27006 Deed Book 426 Poge 166 Allied Associates, P -A. 4720 KeslerMRI Road Plane (336) 765-2377 Winston-Salem, N.C. 27103 FA% 760-9686 .-mail- AS.—yepol.com TOWNSHIP COUNTY STATE DATE Farmington Davie North Carolina 4/04/07 SURVEYED MAPPED: JOB NO. MAP NO. TDS CBO PA070327 MrC.OWG MTC ® Allied Assoc., P.A. 2007 SCALE 1" = 40, SU JM