230 Odell Myers Rd f. � � �
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� DAVIE COUNTY HEALTH DEPARTMENT
� � Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(33fi)751-S1G0
Account #: 990003436 Tax PIN/EH#: 5789-54-8471. B
Billed To: Francis DiGiovanni Subdivision Info:a3�
Reference Name: Location/Address: Odell Myers Road-27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 3948
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S. Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONS RUCTION IS VALID FOR A PERIOD OF F VE YEARS.
Environmental Health Specialist's Signature: Date: �� 6
CERTIITCATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit
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.
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Septic System Installed By: � °�l f
Environmental Health Specialist's Signature:��-�(��/ Date: �
DCHD OS/99(Revised)
.� >. , DAVIE COiJNTY HEALTH DEPARTMENT �
: i • ` Environmental Health Section /,�'�,,�� �
�
. � P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-87(0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003436 Tax PIN/EH#: 5789-54-8471. B
Bilied To: Francis DiGiovanni � Subdivision Info:
Reference Name: Location/Address: Odeli Myers Road-27028
Proposed Facility Residence Property Size: 1 acre
ATC Number: 3948
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction ofa septic 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
Article 11 of G.S.Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type ` #People ` #Bedrooms `� #Baths�
Dishwasher:�Garbage Disposal: ❑ Washing Machine:�Basement w/Plumbing: ❑ Basement/No Plumbing: 0
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply���Design Wastewater Flow(GPD) Site: New❑ Repair❑
d% �
System Specifications: Tank Size�i��GAL. Pump Tank/_��AL. Trench Width�� Rock Depth�� Linear F�`/�
Other: �
Required Site Modifications/Conditions:
IN[PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW
FINISHED CRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 130 p.m.on the da o ' allation. Telephone#is(33O751-87G0.****
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Environmental Health Specialist's Signature: _� �l/ Date:����Q�O�
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DCHD OS/99(Revised)
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✓
(''� � � � � � I 710N FOR SITE EVALUATION/161PROVEh1ENT PERhfIT&ATC
U Davie County Health Department
1 3 2004 Environmenta/Hea/th Section
�E� P.O. Box 84B/210 Hospital StreQt
Mocksville, NC 27028
ET1111RONhM1ENTA�K�H (336)751-8760
*** TIiIS APPLICATION CANNOT I3E PROC�SS�D UNLESS ALL THE REQUIRED
INFORMATION IS PROVID�D. Refer to the INFORMATION BULLETIN for instructions.
�' •/�
� l. Namo to be Billod 1" �"L 1'� C l 5 �t(�/d V!- �n� � Contac t Peraon
Mailing Addreas lO�� �� f'1 S e T ��✓ Home Phone J.�J(C' 7�e ?` " � � ��
City/State/ZIP ���� � �r S /�� C � 7p/L Business Phono
2. Name on Permit/ATC if DifPerent than Above '�j ��.,-, P
Mailing Addrasa Sn ,,,,, � City/State/Zip
3. Applicution For: �—Site Evaluation � Improvement Permi�/ATC ❑ IIoth
4. syatem to service: ❑ House l2J��obile Homo ❑ Business ❑ Industry ❑ Other
5. Type aystem requeatad: [I�d�Conventional � convontional modifiud ❑ innovativa
6. If Residence: # PQople # Bedrooms � H BathroomB �
❑Diahwa�her ❑Garbage Dispo3al �Washing Machine ❑Hasement/Plumbing �Basement/No Plumbinc�
7. Zf Duninesa/Industry /Othor: verify type 1� Poople # Sinks
# Commodea � # Showers �_ # Urinals # Water Coolars
IF FOODSERVICE: # Seata Eatimated Water Usage (gallona par day)
e. Typo of water aupply: CI County/City W�FJell � Community
9. Do You anticipate additiona or c�pai�sions of tlic facility tl�is systcm is intcnded to scrvc? 0 I'cs �No
iry�s,,v>>�t typ��
, _, ***I111PORTANT***CLIENTSAIUSTC0�1tPLETETII� I�QUIRED PROPGRTY INI�ORIYIATIOtY RGQULSTGD
- BGL01Y. �(thcr a PLAT or SITG PLAN MUST IlESUBNIITT,CD by tiic clicnt tivith TIiIS AI'PLICATiON.
�- • .
�� �
I'roperty Dimcusions: 1 G��--� �7 1YIZIT�DIRCC'CIONS(froin 111ocl:svillc)to YROYCRTI':
T�x orr��rrrr: �E�7 ��'� S �/—d""�?/ �Q d I � o c@�� 1�-�-.�/
a--
Property Address: Road Namc_,��� ?'l. f `��i�-, ,
/ City/Zip �S-�
If in a Subdivision proviJc intormation,as follotivs:
Namc: '
Section: Block: Lot: Datc liomc corncrs Ilaggcd: l� ls O
TI�Is is to certily tliat tlie information provided is correct to tlic best of my lcno�vledga I understlnd tliat any per�nit(s)
issucd l�crcaftcr�re subjcct[o suspcnsioc�or rcvocation,if tl�c sitc plans oi'li1�Cll(IC(I USC CI1�I1�C�ol•if ll�c iiifoYlllat1011
submitted in tl�is application is falsired or clianged. I,also, rurrlerstanr!llrnll a�u respo�rsiGlejor nll clra��es iucrurerljruui
t1�is npplrcntio�r. I,hcrcby,givc couscnt to thc Autl�orizcd Represcntativc of tl�c Davic Couuty IIcalth Departmcnt
to cntcr upon abovc descrit�cd property locatcd in Davic County and otivncd by �
tu cociduct�11 tcsting proccdiu•cs as iicccssarJ�to dctcriiiinc tlic sitc suit:iUilit � ,
DATE �y l{ �(C�� SIGNATUI� ' �
TI�IS AREA MAY B�US�D FOR DRAWING YOURSIT�PLAN ncludc all of tl�c follo�ving: �xisting and proposcd
property lines�nd Jimensions, structures, setbacics, anJ septic locations). �
Sitc Revisit Charbc
Datc(s):
Clicnt Notification Datc: '
�I�IS:
Sign given � Accouiit No. �
Rcviscd DC iD(OS/03 I�ivoicc No. �y�
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. DAVIE COUNTY HEALTH DEPARTMENT
� � ` Environmentai Health Section
� Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003436 Tax PIN/EH#: 5789-54-8471. B
Billed To: Francis DiGiovanni Subdivision Info:
Reference Name: Location/Address: Odell Myers Road-27028
Proposed Facility: Residence PropertySize: 1 acre Date Evaluated: � ���
Water Supply: On-Site Well d� Community Public
Evaluation By: Auger Boring L� Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition .L� ,L
Slo e%
HORIZON I DEPTH i' �� �/
Texture rou ;
Consistence
Structure
Mineralo •
HORIZON II DEPTH � ' �/
Texture rou G -�'
Consistence
Structure G
Mineralo �
HORIZON III DEPTH
Texture rou
Consistence �
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
S[ructure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: � � EVALUATION BY: U
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
� � / � L�
REMARKS• � �� / � I�G � �� '� ! gCGt' / i`
LEGEND
Landscape 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
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
Mineraloev
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-gaUday/ft2
DCH�OS/99(Revised)
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NIP W 211.74' cror,��
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PROPOSED NEW 25' W BEGIN OLp
ACCESS EASEMENT FENCE
� 12.2'
� N � 29.7' L
LEE MYERS 1-
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Ro. SARAH Jo a w EN ;3 � EUZABETH COKER'S PROPERTY RECORDED AX PARCEL 42 p� D AX B�OK 2� � NIER �
�, , PAGE 7g3
i ^ IN DEED BOOK 410 AT PAGE 31 S MAP H-
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g a�PBooK �s2, �N�ALLEN �- �
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op� SITE � — — o
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v- �
MYERS RD. � _ �F,'/ o/�N � W4 S SS��8�46�� IRON PIPE Fd. AT T}iE N.E. X
-- �_01i -E_ � b►�� � E 186� i CORNEROF '_
� � ���=UN� '°.o o '� rn; � ef I 7Z --� PROPER1y REFCp DED INDIGIOVqNN)•S ��x ►�.►
AT PAGE 875 DB.411 (P,qR7� OF TAX PqftCEL 42.08 ~
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I � 4P ao ' qp N --_
LOCATION MAP ROAD AT TFiE R/W CE / � 2Jr.�0'
NOT TO SCALE �PER �NFO IN �RUNE �tf i � i � � (D8.138, p�,Zee) � OLD 1/2" IRON STAKE FOUND AT
� � DB.14�, pG,609) � � � � � � TNE N.E. CORNER OF AN OLD TRACT
I ^ W.- i � i ^ o i CORNER RECORDED IN D8.138, PG. 288
3 ; �' � NEW LOT cv co ;
' PROPOSED NEW 25'��, ,y. µ POR�N i � rr�rr O i
ACCESS EASEMENT N ^ 46 ,� �_J 1 .00 ACRE � �
'� �4'X ss• �
I O ^ W o MOBILE HOME i O�p W RE �C��X
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N/P 4� (rOTAL) i 4
25.01' 186.73' NIP � ' �+
o � � �
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PROPOSED NEW 25' W BEGIN OLp w�RE i
ACCESS EASEMENT FENCE � �
N ' �
� 12.2' ?ROPERT( OF a � '`
TOMMY LEE MYERS � � � 29�7� ELIZA�ETH COKER m ; (PART OF TAX PARCEL 42.08) 1
W -� W� NEW LOT 'B�� 28•g' 3 DEED BC�OK 410, PAGE 318 � �
/ � TAX PARCEL 42.08 TAX MAP H9 ' x
LORIE DENISE MYERS � °W� � �'
a w N � " 1 .00 ACRE
� � � SPIGOT� eJ- (V m �
DEED BOOK 141 , PAGE 609 �"� � ��TR��- SQtVICE °p tp Z ; ���-- " \
a � N POLE FOR THE WELL (� 1'� � i
TAX PARCEL 28 TAX MAP H-8 (p O w� o �
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NOTES: //�
; W O� /h�
1.THIS PROPERTY IS SUBJECT TO ANY AND ALL RIGHT(S)-OF-WAY AND
OR EASEMENT(S) WHICH MAY OR MAY NOT BE OF RECORD AS OF THE o � �
DATE OF THIS SURVEY.AND MAY NOT BE VISIBLE UPON THE GROUND. �5.�?' '
�
�
2.FOR THE BACK DEED REFERENCE FOR THIS PROPERTY SEE DEED BOOK �p N\P �gb ��, � //
41 1 ,PAGE 875 (THE DIGIOVANNI DEED) ^ �
°18'46 � i / �
. � 85 "E 211.74'—� NIP � ,-
3,THIS SURVEY CREATES A SUBDMSION OF LAND WfTHiN THE AREA OF A COUN'TY N__ ____�A NEW PRpP�,UNE - TOTAL) , / ---�� `
OR MUNICIPAUTY THAT HAS AN ORDINANCE THAT REGULATES PARCELS OF LAND. ----------__ �°B•��. Pc.2es) ;
THIS SUBDMSION OF LAND MUST ALSO BE APPROVED BY THE CfTY-COUNTY /-� 2,�N�UNE � �� PR��Y �NE ---" � �
PLANNING BOARD AS MEETING THE REQUIREMENTS OF THE SUBDNISION REGULAT I ONS W o B�E►'� DB.138, P�,y� ,y,�p D e.1 8 1, p�,4 7 4) ----'-----_____ � � / \
BEFORE DEEDS ARE RECORDED IN THE OFFICE OF THE REGISTER OF DEEDS. � � (oe.te�, p�,474� ---_____� j \
d' +
N � � � � /
o �r`O. NEW LOT ,►C►► ��Z� / '� �
o " 1 .00 ACRE '�r � / � ��' \
3 / `��
z ( . _ ;d. /. ,�`S�'/�� •
� � / � � �' ��
WIRE � FOUND AT OLp r.�. a (PART OF TAX PARCEI 42.08) �j� � �A��G��
• � F'ENCE CORNER /� � ��
y� P
OlD WIRE � � � �� ^ �
A' �ENCE /� / � \ '
OLA RE FENCE CORNER AT A S W. �_'v 8`�0'O'34���/ �68. 1 X N 5 0'� �� OO,l
.�
CORIrFR OF FRANCIS J. DIGIOVANNI'S 4 , � �/ �� ��
PROPERTY
LEGEND r? W / � yti� Q�
PROPERTY L I NE N � � � '�.�
NOW OR FORMERLY � ;
— ADJ01 N I NG PROPERTY L I NE RAYMOND C. MYERS � / /.�--�
E E E EASENENT L INE
NIP NEWLY SET IRON PIPE a/yV W � .�"
EIP EXISTING IRON PIPE DORIS S. MYERS � w / �� 60 O 60 1Z0 180
EIS IXISTING IRON STAKE FOUND O ; /��• \
ReF REBAR FOUND DEED BOOK 97, PAGE 904 �
PP POWER POLE TAX PARCEL 45 TAX MAP H-9 � � j � GRAPHIC SCALE — FEET
R�R RAILROAD r- _��� \
RiW R I GHT-OF-WAY O 9 ,/��, 5�' � A DIVISION P'OR
EP EOGE OF PAVENENT �—"-
B� BACK OF CURB z �P � FRANCIS J. DIGIOVANNI w� BEVERLY �i. DIGIOVANNI
��S 62°5� '� 4��W 1 O � DIVISION OF PROPERTY RECORDED IN DEED BOOK 411, PAGE 875
����`,`�'CAR����� 37 05' \ TOTAL ARFA OF THIS DIVISION IS 3.00 ACRES
I, RONALD LEE OXENDINE, DO CEKTiFY THAT THIS PUT WAS ��� <<Z�,.•••.. O, ���� IRON PIPE Fd. AT THE MOSf S.W. CORNER '
PREPARED UNDER MY DIREC110N AND SUPERVISION fROM AN ����0.• FESS/�'•;!;,�i OF FRlWCIS J. DIGIOVANNI'S PROPER?Y F I ELD
AC'R1AL FlELD SURVEY PREf'ORMED UNDER MY DIRECTOINAND ; ��r� ���.�'..l� RECORDED IN DB. 411 AT PG. 875 LOCATED CHRISTOPHER N. STI�NLEY TAX MAP TOWNSHIP COUNTY STATE 800K DATE
SUPERVISION, AND IS TRUE AND CORRECT TO THE BEST OF ��y EA L � " S 87°48'S5"E 1.73' fROM A 3/4" REBAR Fd.
MY KNOWLEDGE AND BEUEF . -o:�-��ti3 •�y,` DEED BOOK 334, PAGE 946 H-9 SHADY GROVE DAVIE N. C. 40 DEC. 09, 2004
WINNESS MY ORIGINAL SIGNATURE, REGISTRATION NUMBER, AND ��•S',L �Z'��'\ I TAX LOT 10 TAX MAP H9
SEAL THIS_� DAY OF �L • , 20 O¢ i"' •�S�;,�IFy'�����` PART OF FALUNGCREEK FARM, PHASE: 1 TAX BLOCK RONALD I.EE OXENDINE SCALE
5URVEYING � so
'�� p'••_ ,�� \�� I SEE PLAT BOOK 7, PAGE 48-49 ��_ �
`-:/�� r- � - //����i i i�►i����`°�\ JOB No./MAP SIZE
T A X L 0 T N o. 5430 STYERS FERRY ROAD
RONALD LEE OXENDINE, PLS L-3063 • C L E M M O N S� N.C. 2 7 0 1 2
A DIVISION OF TAX COORD FlLE 200485
LOT 42.05 PgONB: (398) 768-��70 L-9083 Mqp FlLE: 040966