278 Jesse King Rd • HEALTH DEPARTMENT RELEASE
For Office Use Only
ra
r *CDP File Number 122718-1
Davie County Health Department
.d 67-010-BO-001
- 210 Hospital Street County ID Number.
P.O.Box 848 Evaluated For. HDR/WWC
Mocksville NC 27028
Phone:336-753-6780 Fax: 336-753-1680 PERMIT VAUD 0 8 / 0 9 / 2 0 1 8
UNTIL
Applicant: Alex McGuire Property Owner: Alex McGuire
Address: 278 Jesse King Road Address: 278 Jesse King Road
City: Advance City: Advance
StatefZip: NC 27006 StatefLip: NC 27006
Phone : (336)345-2016 Phone#: (336) 345-2016
Property Location&Site Information
rAAddress278 Jesse King Road Subdivision: Laurel Brook Phase: Lot 1
d# Advance NC 27006SINGLE FAMILYTownship:
cture: Directions
#of Bedrooms: 5 #of people: 4 1-40 to Hwy 801 North,right on Yadkin Valle Rd.Right on Jesse King,
pool behind house
*Water Supply: NEW WELL
Basement FJYes❑No Type of Business
Total sq.Footage: No.Of Employees:
'Proposed Improvement:
Pool
'Release Conditions
It is the responsibility of the owner to maintain a 5 foot minimum setback between the wastewater system and any part of the structure
foundation,including porches,decks,and any other appurtenances. If you are unsure as to the exact location of the septic system,please
have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the
proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this
property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed.
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? QYes (ANO
Applicant/Legal Reps. Signature- *Date:
*Issued By- 2244 Daywalt,Andrew *Date of Issue: 0 8 0 9 2 0 1 3
Authorized State"Agent:
* Total Time:01-IMM)
**Site Plan/Drawing attached.
0 1 Hours O O Minutes
(D Hand Drawing OlmportDrawing
•
Davie County Health Department
181fi Environmental Health Section -
P.O. Box 848
210 Hospital Streetg� `
Courier# : 09-40-06
Mocksville, NC 27028
Phone:(336)-753-6780 Fax:(336)-751-8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name: —p,,� Phone Number 33jp'3�5"�? (Home)
Mailing Address: Z7 4 5 k2k 1 nS r`c�i (Work)
L a-7 u ofo Email CG rP ie b mcay i rc h)by)0.j- cam,
Detailed Directions To Site: r i 13v* Ck IIC
�5,/oo&--,
Property Address:
C)o
Please Fill In The Following Information About The EXISTING Facility: /,q C �e �'"" /C
LO
Name System Installed Under: 41M /i`y,61!i rd, Type Of Facility:
Date System Installed(Month/Date/Year): 2 `Z Number Of Bedrooms:—,5_Number Of People:
Is The Facility Currently Vacant? Yes If Yes,For How Long?
Any.Known Problems? Yes If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Number Of Bedrooms: �r Number of People
Requested By: Date Requested:
'(Signature)
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:$ Date:
Paid By: Received By:
Account#: Invoice#:
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All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the 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 or arising out of the use or
Inability to use the GIS data provided by this website.
• DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
3
OPERATION PERMIT
Account #: 990000830 Tax PINIEH#: B7010B0001.
Billed To: Alex McGuire Subdivision Info: Laurel Brook Lot# 1
Reference Narne: :,Location/Address: Laurel Brook Lane-27006
Proposed Facility: Residence Properly Size: 4.66 Acres
ATQ%j6q�q*r*The s uance 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_ Tank Date Tank Size_ZWQ
Pump Tank Size Bedrooms:
y�n C 146 w0wxe�
System Installed By:AIN MU KL Inspector Date:
GPS Coordinate:
Sit
l�
Environmental Health Specialist Date: l
DCHD 11/06(Revised)
' DAME COUNTY ENVIRONMENTAL HEALTH lv
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990000830 Tax PIN/EH M B7010B0001
Billed To: Alex McGuire Subdivision Info: Laurel Brook Lot#1
Reference Narne: LocationiAddress: Laurel Brook Lane-27006
Proposed Facility: Residence Property-Size: 4.66 Acres
FITC Number: 5895 Site Type: AlNew ❑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 Ll #BathroomsLI•C #People 11 Basement❑ Basement plumbingZ
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size Y. Q CSL. Type of Water Supply: ❑County/City [Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)Wo Tank Size GAL.Pump Tank GAL.
Trench Width Max.Trench Depth Rock DepthJ21 Linear Ft.
Site Modifications/Conditions/Other: p L qDl t L(ifl7i yl�L(Alyt Q Ir
Contact the Davie County Environmental Health Section for f nspection o is system between
8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760.
y �
Environmental Health Specialist Date:�01 Zi*Z
DCHD 11/06(Revised)
' Davie County Environmental Health
• P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 990000830 Tax PIN/EH#: B7010B0001
Billed To: Alex McGuire . Subdivision Info: Laurel Brook Lot# 1
Address: 175 Brookside Lane Location/Address: Laurel Brook Lane-27006
City: Advance
Property Size: 4.66 Acres
Reference Name:
PropQ i( i is Rgmprovement 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: INNew ❑Repair ❑Expansion Permit Valid for: ❑5 Years ❑No Expiration ^R
Residential Specifications: #Bedrooms LI #Bathrooms #People Basement❑ Basement plumbingg
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD):!A () Type of Water Supply: ❑County/City &Well ❑Community Well
Site Modifications/Permit Conditions:
System Type LTAR
Initial C a of ZS'
Repair 2St'
Site Plan
Environmental Health Specialist Date
i.p.11-06
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health P 1,^N
P.O.Box 848/210 Hospital Street A
Mocksville,NC 27028 ��1� q
MAR O 9 2012 (336)753-6780/Fax(336)753-1680 BY .�
plication For- aluation/Improvement Permit ❑ Authorization To Construct(ATC)
pplication: 6Prew 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
L
Name Contact Person
Address Home Phone -CCo
City/State/ZIP Business Phone 3 - 61 Lo-
Name
QName on Permit/A C if Dif,�erent than Above
Mailing Address (am m8n.'s City/State/ZipCL
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit'is val'ydfor 60 montbs witsite plarr;no expiration with complete plat.)
Owner's Name 1_%, C'e— Phone Number 93p':,L� f`Z i
Owner's Address CO7 City/State/Zip _L\1-Vy(.,_Kc_Q a
Property Address City_
Lot Size \ ,(��p. C Tax PIN# u B DOC7I
Subdivision Name(if applicable) Section/Lot#
Directions To Site: — c G— : n o c R O o_
If the answer to any of the following ques ions� "Yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? . Yes 'L2-o
Does the site contain jurisdictional wetlands? Yes
Are there any easements or right-of-ways on the site? Yes
Is the site subject to approval by another public agency? Yes ✓_No
Will wastewater other than domestic sewage be generated? Yes
IF RESIDENCE FILL OUT THE BOX B LOW
#People #Bedrooms - #Bathrooms Garden Tub/Whirlpool ❑Yes Cld�
Basement: es ❑No Basement Plum ing: �❑No
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: It-onventional ❑Accepted ❑Innovative ❑Alternative- ❑Other
Water Supply Type: ❑ County/City Water ew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes
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 Healih Department to conduct necessary inspections to determine compliance with applicable
laws and rul erstand t I esponsible for the proper identification and labeling of property lines and corners and
locatin nd ing or s ouse/facility location,proposed well location and the location of any other amenities.
rty o ner's or er's legal representative signature Site Revisit Charge
��O/� Client
e(s):
��p � Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice# Pd.
�v✓
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990000830 Tax PIN/EH#: B7010B0001
Billed To: Alex McGuire Subdivision Info: Laurel Brook Lot# 1
Reference Name:- Location/Address: Laurel Brook Lane-27006
Proposed Facility: Residence Property Size: 4.66 Acres Date Evaluated: _�?(�
t
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit 4 Cut
FACTORS 1 2 3 4 5- 6 7
Landscape position
Slope% 20-1,
HORIZON I DEPTH
Texture groupL-
Consistence i
Structure / ,--
Mineralogy -:* 1; lAlz
HORIZON II DEPTH
Texture group
Consistence
Structure'
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS .4` ciw J '�
,RESTRICTIVE HORIZON
SAPROLITE ea
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: P5 EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
LLandseape 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
��41S1t
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
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
Note.
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)
5 10—
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C
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point
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_ Al
105 Acres
o �
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CP
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NIP134. 8
NiP S 55620'00"E
NIP S 53°13.0 "E
N 89 10'�
'c 15�
•'`? COCO
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5.014 Acres 1 �'
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DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'INFORMATION PROPERTY INFORMATION
Account #: 989900641 Tax PIN/EH#: 586348-3164
Billed To: David M. Hanes Contracting Inc. Subdivision Info: Laurel Brook Sec. B Lot#1
Reference Name: David Hanes Location/Address: Jessie King Road 27006
Proposed Facility: Residence Property Size: 5.105 Acres Date Evaluated: IZ Q
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit - Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope% 3
HORIZON I DEPTH p •L _
Texture group S
Consistence G 5 A/P O
Structure G2 62
Mineralogy M► X,,r0
HORIZON lI DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS Z
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE p• 7—
SITE CLASSIFICATION: PS C E»G -To a � � EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: 'hkUt
REMARKS: J Irn i7L;�p 44-a4 ALot(v aj06a 64-- STWIP o-1 Sipes
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
Wet
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
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)
LIAR-Long-term acceptance rate-gal/day/ft2
DCHD 05/99(Revised)
APPUCATION FOR SPIE EVAATION/IMPROVEMENT PERMR&ATC D
� 0��
W
Davie County Health Department
Env vnmenW Heaft Section NOV 1 9 1999
P.O. Box 848/210 Hospital Street
Mockaville, NC 27028
(336)751-8760
***XMMTANT*** THIS APPLICATION CANNOT BE' PROCESSED UNLESS ALL THE RZQUYIMF
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed��f�V1 L1 rn �JANGS C OJ 1 CA�!t►qty iM�. contact Person M A U% �1"A N
Meiling Address 3 CS 1A c, di t r4'i Roos Phone clq�S• 5 1 p7
city/state/exp 60VI-"'CE!!J C.. - 2-700(b suainees phone 9qg-50: m.3 iT-IIt0
2. Mass on Perait/A= if Different than Above %eet Z" 770-11s,
Mailing Address city/:tate/Lip
3. Application For: Pleite Evaluation ❑ Improvement Permit/ATC ❑ Both
4. system to serviosi "Ouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. It Residence: t People ! Bedrooms ! Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ Mashing Machine ❑ Basement/plumbing a Besemmnt/NO Plumbing
6. ZE Business/zndustry/Others specify type ! People ! sinks
! Commodes ! showers ! Urinals f water coolers.-
Ir FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. . Type of Mater supply: ❑ County/City U4e13. ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes ❑No
If yes,what type?
***IMPORTANT***CUENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBM17M by the client with THIS APPLICATION.
Property Dimensions:. S. l OS C—' WRTTE DIRECTIONS(from Mockwi te)to PROPERTY:
qS, - G 11 /01
Tax Office PIN: # S e 4-
Property Address: Road Name fit±Sst F K rwe�hoc�l
Cityaip rA zyAN Z g•. Xlco 6
w
U in a Subdivision provide information,as follows:
Name: LaOA E'1 Q aOo K f
Section: 1 Block: Lot: �_' %Date Property Flagged: 101 16 k A.1
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 Incurred from
this application. I,hereby,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 ZG s,r illi Yh.kel C—'VmX1&%
to conduct all testingproceduresas necessary to determine the site suitability.
DATE I R E��1SIGNATURE eA.JI
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} 6/` z/�y/
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
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Davie GountV)Yealth Department
Enwronmental)Yealth Section
PO Box 848/210 Hospital Street
Mocksville,NC 27028
Phone: (336)751-8760
May 31,2000
William McCarthy
131 Brentwood Drive
Advance,NC 27006
Re: 2 Site Evaluations-10.498 Acre Tract
Laurel Brook/Lot#5
Tax PIN#: 5863-48-9271
Dear Mr. McCarthy:
As requested,a representative from this office visited the above site(s) on May 31,2000.
It should be noted that this tract was originally evaluated on December 7, 1999 and classified
provisionally suitable for a single residence. The evaluations that were performed today reflect,
dividing the tract into two approximately five-acre tracts. Based on the information provided on
the Application for Site Evaluation and after the evaluations were completed, both sites were
found to be provisionally suitable for the installation of an on-site sewage disposal system.
Site A was evaluated for a three-bedroom residence. Based on the evaluations performed
today and the previous evaluation at the site, approximately 600 linear feet of drain line will be
required for this three-bedroom house. Site B was evaluated for a four-bedroom residence.
Approximately 600 linear feet will be required for a four-bedroom house on this site. Based on
the proposed house locations, no pump station will be required for either system However, this
is subject to change and actual design and dimensions of the septic drain field will be determined
at the time a permit is issued.
Before a representative of this office will revisit the site to issue an Improvement
Permit/Authorization to Construct, the appropriate application must be completed in full and
submitted to this office. The location of the facility the system is to serve must be staked off.
If you have any questions,you may contact our office at (336)751-8760.
Sincerely,
Jeff G. Beauchamp, R.S.
Environmental Health Section
enc(s)
rarca ;uu
Tax Map B-7 \ Troct t t
Virginia G. Walker River Bend Hills
D.B. 075-153 \ P.B. 6. P. 162 ryo� David M. Hanes tA N
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5911 0°� �S 36°49.35"E 61.03' / 3
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9 1 71.27
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Parcel DaidpHanes
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Owner : David M. Hanes Cont
301 Han
Advonce
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