352 Liberty Church Rd ,___. ._�, , DAVIE COUNTY ENVIRONMENTAL HEALTH � �
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P.O.Box 848/Z10 Hospital Street ,�
Mocksville,NC 27028 c \1
(336)753-6780/Fax#(336)753-1680„ ., „U
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�. OPERATIOi�T PERMTT ��
Account #: 990005898 •: .� .:: �'�x:Pi�.�EH�: E300000018 ,. . � . . .
Billc�70: Joshua Moody Jennifer Moody ` ?".Suf�divi�iori.lnfn:, r;:r; _, °',;, ,< • , .
Refer�r�ce Nar��e: . .:`: .. : ;'•.,:LocationiAddress: Liberty Ch Rd-27028 •: : : :; °., .
Propas�d F;��:ilify: Residence r,,,;�,; ; s:.;,,°,;: �ro��riy�S�ize: 1.13Acre � . . . . i: .- .
.. ry�,
: t�T,��(��,�:��59�5�ce of this Operarion Permit�h�all 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. ��`34, _ .
System Type.;__ S.T.Manufacturer�5��t-T Tank Date o�� Tank Size /�O
Pump Tank Size Bedrooms:�_ , .
System Installed By:� � i� Installer# Date:_���a s
GPS Coordinate: '
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Environmental �Iealth Specialist Date:�' o?v� o/
DCHD 11/06(Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Acct�unt #: 990005898 . ' Tax"�It�IEH#: E300000018 . .
�ill�;d To: Joshua Moody Jennifer Moody 5ubdi��iori ln#o: ,��" �: � . ..: • - , .-
R�fer�r�ce Nan�e:: -.:. . �� . " LocationiAddr��s: Liberty Ch Rd-27028 : ; °
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E�ro�c�sed F��:ility: Residence , , �: . P�b��r#y�Siz�: 1.13 Acre ` , . � .,
ATC �i�arnb�r: 5952 ., . ._;
Site Type: �New ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MLJST 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 Z #People y Basement❑ Basement plumbing❑
Non-Residential Spec�cations: Facility Type #People � #Seats
Square Footage(or Dimensions of Facility)
Lot Size .�. �..C. Type of Water Supply: �County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD)�L�Tank Size fC��GAL.Pump Tank �AL.
Trench Width �` Max.Trench Depth�� Rock Depth/l��Linear Ft. , ��� c.��C
Site Modifications/Conditions/Other: ������n.
. Contact the Davie County Environmental Health Section for final inspection of this system between
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Environmental Health Specialist Date: 0
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APPLICATION FOR SITE EVALUATIONIIlvIl'ROVEMENT PERMIT & ATC
�'`��.�" Davie County Environmental Health `, ��,���,/�
P.O.Box 848/210 Hospital Street
� �l1�.. � � �Q12 , Mo���ne,:Nc 2�o2s JUL 0 5 2012
, ! � � (33�753-6780/Fax(336)753-1680
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Application For: ❑ Site a7uation/Improvement Permit � Authorization To Construct(ATC) Both
Type of Application: ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTAN7***THIS APPLICATION CANNOT BE PROCESSED UNLES S ALL OF THE REQUIRED
INF'ORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name nt�� Contact Person
� Ic9 j (\1G �w�� R01 !l� Address Home Phone
City/State/ZIP J'���5���1�T�j�_ a?Da� BusinessPhone `10�-' �� ���Oq3
Email
Email: G�
Name on PermidA ifD�erent than
Above �,r,«,
Mailing Adc7ress City/State/Zip
,
PROPERTY INFORMATION *Date House/Facili Corners Fl ed
NOTE: A survey plat or site pian 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 �rPd �fl d�,, n�l L. Phone
Number ,
Owner's Address �Q� Shn-�Q I� 7�. '� - s; "rC. City/State/Zip r,mr,,,,�, ,�VG ��b 3�
Property Address L� City
Lot Size �, ��j �,�r'� Tax PIN# •S 3 ar�,� � 3 O 0 o a DO�
Subdivision Name(if applicable) � ection/L,ot#
Directions To Site:
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If the answer to any of the following questions is"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? _Yes ✓No
Does the site contain jurisdictional wetlands? _Yes ✓No
Are there any easements or right-of-ways on the site? _Yes ✓No
Is the site subject to approval by another public agency7 _Yes �/ to
Will wastewater other than domestic sewage be generated? Yes ✓No
IF RESIDENCE FII,L OUT TI�BOX BELOW
#People #Bedrooms � #Bath�r oms � Gazden TublWhirlpool ❑Yes o
Basement: ❑Yes o Basement Plumbing: �Yes C�'No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilitylBusiness Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Esrimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats • '
Type system requested: ❑Conventional Accepted ❑Innovative ❑Alternative ❑Other
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underst d that I am respo ible for t e proper identification and labeling of property lines and corners and locating and flagging or
st 'n e house/fa ' locati tiposed well location and the location of any other amenities.
Property o er's or owner's legal representative signature Site Revisit Charge
Date(s):
� o� Client Notification Date:
Dat EHS:
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� � � � Davie County Environmental Health
-- - P.O.Boz 848/210 Hospital Street
� Mocksville,NC 27028 .
� (336)753-6780/Fax(336)753-1680 ,
IMPROVEMENT PERMIT
Account #: 990005898 Tax PIN/EH#: E300000018
Billed To: Joshua Moody Jennifer Moody Subdivision Info:
Address: � 4101 NC Hwy 801 North Location/Address: Liberty Ch Rd-27028
. City: Mocksvile Property Size: 1.13 Acre
Reference Name: " �
Proposed Facility: Residence • .
**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 13OA,Wastewater Systems). This Improvement Permit is subject to �
revocation if site plans,plat or the intended use change. .
Permit Type: ES�1ew ❑Repair ❑Expansion Permit Valid for: �e!'SYears ❑No Expiration
Residential Specifications: #Bedrooms�#Bathrooms�#People�Basement� Basement plumbing❑
Non-Residential Specifications: Facility Type � #People " #Seats
Squaze Footage(or Dimensioris of Facility)
Design Flow(GPD):�e�ccv Type of Water Supply: �.County/City ❑Well ❑Community Well
Site Modificarions/Permit Conditions:
S stem T' e LTAR '
Initial 0
Re air � � �
Site Plan .
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` Environmental Health Specialist � � Date (� V�
. i.p.il-06
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' - �' Davie County Environmental Health
� P.O.Box 848/210 Hospital Stre�t � - .
Mocksville,NC 27028 �
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
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Account #: 990005438 Tax PIN/EH#: 5811-76-9034
Billed To: Fred Beck Subdivision Info:
Address: 591 Sheffieid Road ' Location/Address: Liberty Church Road-27028
City: Harmony property Size: 1.13 Ac. "
Reference Name:
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the constructioti 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.
__..�._�____._.Y,.._._.....____.�_______._.____ _._.._.�.____.�.______.__._......___.�..---_._._...._._.__,____�.._._...._................_.__.__. __ _...___...._ ...
Permit Type: �New ❑Repair ❑Expansion Permit Valid for: �Years ❑No Expiration
• Re§idential Specifications: #Bedrooms�#Bathrooms Z- #People Z Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): 3� Type of Water Supply: llCounty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions:
S stem T e LTAR
• � Initial
Re air "/d ^ , �
Site Plan �
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Environmental Health Specialist Date .2
i.p.l l-06
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' + r AP A�I'� TE EVALUATION/IMPROVEMENT PERMIT & ATC
�,,, � � avie County Environmental Health
;'� 2 6 ,��10 P.O.Box 848/210 Hospital Street
��1 � Mocksville,NC 27028
� � F�� ����,�N 36)753-6780/Fax(336)753-1680
Applic ion F • �,�ffS�M1�`��@il�l°�� mprovement Permit ❑ Authorization To Construct(ATC) ❑ Both
Type of pplication: System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMP RTANT.*** TIIIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED ,
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed ��K Contact Person �iPQ� ,�e��
Billing Address �' �-'. Home Phone .� - �- / : 7,5,�'�
City/State/ZIP �G �J f✓_�2�'���_L'usiness Phone -- ��_ �
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� Nan,e on Permit%ATC if D�erent than Above
Maiiing Address________ __ _ City/State/Zip �
iPROPERTY INFORMATION _ *Date House/Facility Corners Fla ed p� r�l�/, ' V
NOTE: A survey plat or site plan must accompany tliis app(ication. Included: ❑ Site Plan ❑Plat(to scale)
(Pennit is valid for 60 months with site plan,no expiration with complete plat.)
Owuer's Name � Q,�e Phone Nutnber �p�-�i�6--7Sa
Owner's Address S'�/ S,�p�" -�=�i��[�--- City(State/Zip�inQ,tJfr /)J��.�'6��
Property Address �r}� �,�1 City r/�SGt�J/� �� a,�o%�"'
Lot Size � Tax PIN#��g/[ 7b p,?
3,�----- t y
Subdivision Name(if applicable) ';' Section/Lot#
� Directions To Site:� /110� f--a L� a..74, C,(�,Q,c.,[ ��., . �y,,2,�, �� ;��'�j�
�s-�� �,,___�,�LG �'��P�-ss ,���2,�I�,
lf the answer to any ofithe following questions is"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? Yes No
Does the site centain jurisdictional wetlands? Yes No
Are there any eascments or right-of-ways on the site? Yes No
Is the site subject to approval by another public agency? Yes No
Will wastewater otii�r tnan domestic sewuge be generated? Yes No
IF RESIDENCE FILL OUT THE BOX OW �
#People �. #Bedrooms oZ #Bathrooms /�� -a. Garden TublWhirlpool ❑Yes C�No
Basement: ❑Yes 6�No F3asement Flu in�: �IYes �.No
Ir NON-RESIDENCF. FILL OUT'THE BOX BELUV�' -r�' .._.�
�Type of Facility/�3usiness _ � Total Square Fc�otage of Building_ _#Yeople_
#Siriks #Commodes � Showers # LTrinals '
Estimated VVater Usage(gallons per day) (P.ttach documentation of similar facilit}� water consumption)
FOODSERVICE UNLY: #Seats
Type system requested: �Conventional f7Accepted [7lnnovative OAlternative �Other ^_ ._
Water Supply Type:f�'Count}�/City Wat�i � New Nell ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this sysfem is intended tc�serve? 0 Yes l7 No
If yes,what type'1 --- — ----- — _�— __
_ __ ._
. __ . ._. ..___._ _. __. _. ..__ . . . _
1 _
This is to certify that the information provided on this application is tru�and correct to the hest of my know�ledge. I understand
that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if ihe sitc is altered,the inten;ied use
changes,or if the information submitted in this application is falsified or changeu. I hereby grant right of entry to the Authorized
Representative of the Davi:County Heal[h Departnient to conduct nzcestiary inspections to determine compliance with applicable
laws and rales. I understand that I am responsibie;or the proper identification avd labeling of property iines and corncrs and
locating an fl�or staking the houseHiicilitv Iocation,};ro}�osed wetl Ic�cation ar.d the locatic�n of any other amenities.
��� Site Revisit Char�*e �
Propeity uwr►er s or owner's legal represent 've s;gnature
� Date�s):
07`p26'�f� Clicni N��:it:cation Date _
Date i E�IS:
� -- -- �
Sign give;� �.-�Yes ❑'�lo :�ccount# ��3g
Rcviscd 11i06 .Invuice# `P$!lb .SB'�j:�
• , � ' , , DAVIE COUNTY HEALTH DEPARTMENT
� .
� ' Environmental Health Section
� Soil f Site Evaluation
APPLICANT INFORMATION I'ROPERTY INFORMATION
Account #: 990005438 Tax PIN/EH#: 5811-76-9034
Billed To: Fred Beck Subdivision info:
Reference Name: LocatioNAddress: Liberty Church Road-27028
Proposed Facility: Residence PropertySize: 1.13 Ac. Date Evaluated: ,�� O
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition f=
Slope% o L'
HORIZON I DEPTH v� Q_
Texture grou
Consistence
Structure
Mineralo ' •
HORIZON II DEPTH �'
Texture rou C
Consistence ' �
Structure
Mineralo � -=�
HORIZON III DEPTH
Texture rou •
Consistence
Structure
Mineralo
HORIZON IV DEPT'H
Texture rou
Consistence
Structure •
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION; �S EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: •� OTHER(S)PRESENT:
REMARKS:
LEGEND
Landcc,ap�Positi n .
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
T�ciurg
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
�,ONS ST+.N .F.
1�Q1S�
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely fum
� , r
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
StrLctLre
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
1:1,2:1,Mixed
L�Iszt� .
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)
TTAR -T.nno-tP.rm arrr.ntanrr ratr_ aal/�ia��/ft� r�nTm nc�ne m__:__��
Davie County,Nc ' _ Tax Parcel Report Thursday, July 5,2012
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Parcel Information
Parcel Number: E3DDOOOD18 Township: CLARKSVILLE
NCPIN Number. 5811769034 Municipaliry:
Account Number: 5832000 Census Tract: 370.59-801
Listed Owner 1: BECK FRED ERVIN Voting Precinct: CLARKSVI��E
Mailing Address 1: 591 SHEFFIELD ROAD Planning Jurisdiction: Davie County
City: HARMONY Zoning Class: DAVIE COUNTY R-20
State: NC Zoning Overlay:
Zip Code: 286340000 Voluntary Ag.District: No
Legal Description: 1.13 AC LIBERTY CHURCH RD Fire Response District: WILLIAM R.DAVIE
Assessed Acreage: 1.12 Elementary School Zone: WILLIAM R DAVIE
Deed Date: 12/1975 Middle School2one: NORTH DAVIE
Deed Book/Page: 000970463 Soil Types: MnB2
Plat Book: Flood Zone: X
Plat Page:
Building Value: 0.00
Outbuilding 8 Extra 0.00
Freatures Value:
Land Value: 19950.00
Total Market Value: 19950.00
Total Assessed Value: 19950.00
_._ ____
r�� All data Is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the
v:'.F implied warranties of inerchantability or fitness for a particular use.All users oi Davie County's GIS web6ite shall hold
,V�== Davie County,NC harmless the County of Davie;North Carolina,its agents,consultants,contractors or employees from any and all claims or
^°��"� causes oi action due to or arising out of the use or fnability to use the GIS data provided by this website.
: � . ., .
� � � - � � DAVIE COUNTY HEALTH DEPARTMENT
� Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION . � PROPERTY INFORMATION
Account #: 990005898 Tax PIN/EH#: E300000018
Billed To: Joshua Moody Jennifer Moody Subdivision Info: .
Reference Name: Location/Address: Liberty Ch Rd-27028
Proposed Facility: Residence Property Size: 1.13 Acre Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e sition �
Slo e% .
HORIZON I DEPTH
Texture rou _
Consistence
Structure
Mineralo
HORIZON II DEPTH •
Texture rou ,
Consistence
Structure
Mineralo .
HORIZON III DEPTH
Texture rou
Consistence '
Structure
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:
REMARKS: , : .
� LEGEND
L�ndscape Position :
R-Ridge S-Shoulder L-Linear slope FS-Foot slope � N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope
T�tiug
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
ONSI4T .N .
MQls� : ,
VFR-Very friable FR-Friable FI-Firm VFI-Very firm ; EFI-Extremely fum
��t , •
�� NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky :
' NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
,StT.li��
SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky ,
SBK-Subangulaz blocky PL-Platy PR-Prismatic '
Mineraloev _
1:1,2:1,Mixed � _
LlatisS .
Horizon depth-In inches
Depth of fi11-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-gaUday/ft2 , . DCHD OS/OS(Revised)
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EXAMPLE SITE PLAN '
This example was prepared to assist you in drawing your`�own site plan. ,
Without your site plan we cannot perform the site evaluation. If you have
any questions, please call (336) 753-6780.
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http://maps.co.davie.nc.us/GoMaps/map/map.cfm?CFID=4129&CFTOKEN=61640881 3/3/2010