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137 Parkway Ct Lot 24 Only HEALTH DEPARTMENT RELEASE For office use 91288-1 CDP File Number.. �Y Davie County Health..Department. 6Y e r�tv�, 210 Hospital Street County ID Number. P.O. Box 848; HDR/WWC Evaluated For. •°� - *• Mocksville NC 27028`' Phone: 336-753-6780 Fax:336-753-1680 PERMIT VALID 0 3 / 1 3 / a 0 a 0 UNTIL F ant: Robert and Sheila Wilcox Property Owner. Robert and Sheila Wilcox ss: 137 Parkway Court Address: 137 Parkway Court y: Mocksville City: Mocksville StatefZip: NC 27028 State2ip: NC 27028 Phone#: (607) 237-3151 Phone#: (607)237-3151 Property Location 6 Site information Address 137 Parkway Court Subdivision: Northbrook Phase: Lot 24 Road# Mocksville NC 2702$ SINGLE FAMILY Township: 'Structure: Directions #of Bedrooms, 3 #of People: Hwy 601 N.left on Ijarnes;Ch Rd.,then Right onto Northbrook Trail then right onto Parkway Court 'Water Supply: N/A Type of Business: Basement: F1 Yes D No Total sq. Footage: No.Of Employees: =:J 'Proposed improvement: -7 Garage 30x40 C'Release Conditions i Maintain 5 foot setback to any portion of the septic system. i "I"— j 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 ONO, Applicant/Legal Reps.Signature: '_*Date: *Issued By: 2140-Nations,Robert *Date of Issuer 0 3 1 3 / 2 0 1 5 Authorized State Agent: _ `–��"� **Site Plan/Drawing attached.** i, '` OHand Drawing OlmportDrawing s. Davie County Health Department ' i6r Environmental Health Section , P.O. Box 848 ' 210 Hospital Street j CLQ �� � Courier# :09-40-06 1911 Mocksville,NC 27028 Phone:(336)-753-6TZ Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: 11 Ce)X Phone Number '( � J'/ J (Home) Mailing Address: GL U (Work) Jr Email Address: Detailed Directions To Site: Ls Ufa L © On of l Y� a Property Address: Please Fill In The Following Information About �he E�TING Facility: Name System Installed Under: Type Of Facil Date System Installed(Month/Date/Year): Number Of Bedrooms: i� ��— Number Of People:_ Is The Facility Currently Vacant? Yes 00 If Yes,For How Long? Any Known Problems? Yes If Yes,Explain: Please Fill In The Foullowing Information About The NEW Facility: Type Of Facility: 0- Number Of Bedrooms: 0 Number of People Pool Size: Garage Size: C a Other: Requested By: Date Requested: Signature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: 2- - 16- ?-6tS *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: CasMoney Order # 6ULIZI Amount:$ MOT-66— Date: Paid By: Received By: Account#: ,T Invoice#: `NAUTI P,IION NO: 1411 DAVIE COUNTY HEALTH DEPARTMENT ►► 3� s . ` Environmental Health Section PROPERTY INFORMATION Permittee'S P.O.Box 848 " Name: f:tCDAQWICKS Mocksville,NC 27028 Subdivision Name: Angn 6&01< {{�'���wltS Phone#:704-634-8760 j Directions to property: (N)1,J -b-1urSection: g Lot: r / AUTHORIZATION FOR _(�i ,"SJQr1 r L-47 0.! �;Qi#l6etoFSYSTEM WASTEWATERCONSTRUCTION Tax Office PIN:#5 Q0 412 - Z10? "Tar3d^► NaZKWhYCp I�oadwame: fXe1ZW4VCrZip: 0*707, **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 f G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) / 1 ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ,15 9 IS VALID FOR A PERIOD OF FIVE YEARS. OAS EALTH SPE ALI DATE I SUE f ,RESIDENTIAL SPECIFICATION:BUILDING TYPE H OOSf#BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes No COMMERCIAL SPEcTFFII`cATION:FACILrrY TYP/F #f PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE ��^TYPE WATER SUPPLY YDESIGN WASTEWATER FLOW(GPD) NEW SITE �r REPAIR SITE SYSTEM SPECIFICATIONS:TANK SIZE WO GAL. PUMP TANK GAL. TRENCH WIDTH A'' ROCK DEPTH 12 LINEAR FT:cl OTHER ' !1,ISTQI�11TIpa. X REQUIRED SITE MODIFICATIONS/CONDITIONS: IIl_g&t-I. U..SC.c>,VVor)t?, u%EG S1 aF &w 1/%0 1o' IMPROVEMENT PERMIT LAYOUT , 1 A ' Nous:: Faw4r tog,-, e �r **CONTACT A REPRESENTATIVE OF THE DA COUNTY HEAL EPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-I: P.M.ON THE DAY F INSTALLATION.TELEPHONE#IS(704)6348760. OPERATION PERMIT Tit, L Y M INSTALLED BY: Cl 41�I IJ IDGC.K IIW�3 AUTHORIZATION NO. +''+I 1 OPERATI PE IT BY: DATE: _G1/7_d **THE ISSUANCE OF THIS OPERATION PERMIT S L ICA THAT THE STEM DESCRIBED AS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTIO 9 "SE AGE TREATMENT AND DISPOSAL SYS S",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SA FA ORILY FOR ANY GIVEN PERIOD OF TIME. I� DCHD 05/96(Revised) - 24 172 23 125 22 2118 X123 W ; 0 136, ,�' 492 0115 137 141 F„k 25 1 .�-4 pA42K'WAYCT _ � - � 1 136r�� r I` 1 r ; 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 Pri nted:Fe b 23 2015 CJ. of the use or Inability to use the GIS data provided by this website. + 4 'Z� /Vo r4 h bk, 3 3 ��tie }'r 99a�w>;C `f,y v i.i Yii G Yi:�1.='. ; t :µA•�.. `i ..'S•ir a..'>v y5 .\.. - Tj�! q X,.�T•iJ•.�v t � lv w ! 5>=�.r,y 4 kr t�4' �Yu:. �.; —.. � ,l 0.t; "AUTHQ=*riON NO: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee's P.O.Box 84$ Name: rk> Mocksville,NC 27028 Subdivision Name: pj)p�M&¢cK Phone#: 704-634-8760 _Directions to property: (en It3 ao Section: Lot: AUTHORIZATION FOR t a . " 11Q -i C��}s Cs.,! tom;�l►E K WASTEWATER Tax Office PlN:# --� SYSTEM CONSTRUCTION ` "'V- l '-I t'tIT Ofd. Na'g ,W4�r�'T' 1�d7ame: L&le V Jd Zi Z-2o **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying.for Building Permits. (In compliance with Article I fof G.S.Chapter I30A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) r ` / ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. vig-W EALTH SPE ALI DATE I SUE �` t w<A� .'�f 4y. «Ls ��`dr „qp-rte-•• .in* jL�k..s:`"+• s �r �.i-f v.< yy .1' � of •. t � i - { v. Pf. �....,, DAVIE COUNTY HEALTH DEPARTMENT iV1 IMPROVEMENT AND OPERATIO ,PERMITS PROPERTY INFORMATION :r Permitlee's ,•i'- _ , ` } Name: f.�3�", A TP4 Subdivision Name: 13�,(r?' �l?_6oEy Directions to property: t t 0 1�++ � Section: Lot: t IMPROVEMENT ir^ad)14 ;' :30 04 ^.I t�r.p �tl =4� PERMIT ;� Tax Office PIN:# �.e7 - 1t.,4 et•- Na Roadme: 1 ''?. jYti7" Zip : cr 1I.'lis **NOTE**This Improvement Permit DOES NOT,authorize the construction or installation of aseptic 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 Articlel 1,of G.S.Chapter 130A;Wastewater Systems,Section.1900.Sewage Treatment and Disposal Systems) a,f.. a / ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER L'NVIRONM At EALTH SPEQL-,ST DATE I SUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION:BUILDING TYPE F#BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFr2' #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE L-2-7—A&E EC:TYPE WATER SUPPLY ` YDESIGN WASTEWATER FLOW(GPD) NEW SITE � REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE'MOGAL. •PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 12 LINEAR FT.` -%--'C�'?. OTHER ' l�IS�Qltrflr !7�X REQUIRED SITE MODIFICATIONS/CONDITIONS: ��r�T � - p1-S(-0 ZTl;�)�, I�i:�� off. 1�C•i)' .I4tctP ��r t��� IMPROVEMENT PERMIT LAYOUT 4 I ,C. - /ov' ' 1,x.1 Hot) ~ Zoo "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(704)634-8760. OPERATION PERMIT [[ YSTEM INSTALLED BY: 11z A o, ell 1 7C J� AUTHORIZATION NO. i r I OPERATION PERMIT BY: DATE; 7,7h **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THEQYSTEM DESCRIBED A 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. DCHD 05/96(Revised) • APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT (;} Davie County Health Department Environmental Health Section P.O.Box 848 MAY � � 1998 Mocksville,NC 27028 (704)634-8760 ENVI pAVMENTAI HEq ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLE E COUNTY ALL HE REQUIRED INFORMATION IS PROVIDED. /� < 1. Name to be BilledIQContact Personl //1., Mailing Address 13 9 (,v i7a J4'AUE/! �- Home Phone City/State/Zipy QL v'�I/ /V'6- o 70ay Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation C7 Improvement Permit&ATC ❑ Both 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms _ # Bathrooms a Dishwasher ❑ Garbage Disposal O Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage(gallons per day) 7. Type of water supply: Y County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes W No If yes,what type? PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE e� SUBMITTED WITH THIS APPLICATION. Property Dimensions: "� 1 WRITE DIRECTIONS(from - � - �/l� ; Mocicsville)TO PROPERTY: Tax Office PIN: # >42 wg Cou `f ' 6 i Property Address: Road Name 1� r 1 �-• // /�/ City/Zip 1 1 p,-J 11,k If in Subdivision provide information,as follows: 1 Name: 6 D5k S u_L CLQ 1)I'SI,&1J 1 h / t Section: �S� Lot #• 1 1 C 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 ld e e 4 to conduct all testing procedures as necessary to determine the site suitability. DATE SIGNATURE Revised DCHD(06-96) mpm on :LOT X17 � . �. .�, �'• - LOT #20 �'�"C°rwW a (0.942 AC.) s (2.913 AC.) l�0ii8 N 8J11D u1BDN�• `\ LOT #16\ \\116 \ \\(i.162 AC.) \\ Carl em chormcln —03W87 E 436.94 140.00 ONVw yat � �• ! 71.94 LOT 15\ \ / °��, «,mob ` '�"'�°°� (1.098) \\ \� � '�1 � � �.00 «� !za G /• ' DAVE MM Jo LOT #21 '� �� LOT 23 (0.694 AC.) -' (0.880�.) LOT #22 LOT #24 r L . (0.750 AC.) W (1.225 AC.) W IL CoR"ot in Its OD o a �OU.RT LOT #25 LOT #30 ��` (1.104 AC.) (0.898 AC.) _C23 8 LOT #29 f ' (0.700 AC.)� y LOT #28 w (0.789 Ac.) LOT #27 LOT 26 ti (0,705 Ac.) to f (0.855 Ac.) 31 CA Q Z = y 100. V- lootoo 9moo 1000 100.00 70. 100.00 19&93 °• A A APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERM U Davie County Health Department SEP 8 Environmental Health Section P. O. Box 665 11 1 Mocksville, NC 27028 ENVIRONMENTAL r DAVI F 1. Application/Permit Requested By eaa.ZZ ✓y�A Mailing Address /�`C�� CSIX Home Phone !29,9#7 7 Business Phone' 2. Name on Permit if Different than Above t 3. Application/Permit for: VGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: [P/House ❑ Mobile Home ❑ Place of Public Assembly { O Business ❑ InOther ❑ Unknown /a�( 5. If house, mobile home: Subdivision wo l�RabtSe tion Lot# — ❑ Basement/Plumbing No.of People ❑ Basement/No Plumbing No.of Bedrooms ❑ Washing Machine No.of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No.of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: p'Public 7 ❑ Private ❑ Community 8. Property Dimensions I 12A&4,YQAG Sewage Disposal Contractor 7 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes,what type? 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: O , �, h✓Yti (� �,�y�Jy C�� / j 7►Gti �' C��%k% , This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. /,g 9.ham DAT[_ SIGNATURE CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: 1. I OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: 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 to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. 4 DATE SIGNATURE DCHD(12-90) A .A .� • • `DAVIE COUNTY HEALTH DEPARTMENTp� ` Environmental Health Section Soil/Site Evaluation NAME ci�� DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY " ` `" LOCATION OF SITE Water Supply: On-Site Well _ Community Public Evaluation By�'Z1"' Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position Sloe % - 1 HORIZON I DEPTH $ Texture group CL- Consistence Structure Mineralogy '. l HORIZON II DEPTH LAOrr Texture group Consistence Structure 1� 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 . SITE CLASSIFICATION: S' EVALUATED BY: LONG-TERM CCEPT NCE RATE: • ~ OTHER(S) PRESENT: 0 N'2 REMARKS: NK� Y X_ � ' 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 :lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vc-y 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 Mi neraloiry 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(01-901 o - � ■■■■■■..■..■■■..■■...■■...■■....■■■■....Nee■..■■■ .■■.■.■■ ■OMEN.■ ....fl...■■...0■..........................�...► MINIMUM ■■MEMO .. ..........................�............. .001 ■ a MEN MMEMEMME No ■.■■■■■.■..■■■■■■.■■.■■..■ ■MEMO■■.O■OM■■■MME�1■.■ .■■EOM■■E■■■■■■■ ■.■■....■....■■■.............■.IS■■..■■■■■MME.00.■■OMO■■■E■■■/■■ 5:::.:::a:::::::►::a::CMMNMMMa::':■: ......I.n..■■.■N.■M.E.■......E..�■..■.E.HE:::"i:S::Si:a::i.i�MEN ......��......................... ■E■■■■.. 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