175 Pine Forest Ln v • .. �
. ,, �� � DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street ,.
Mocksville,NC 27028
(336)751-8760
Account #: 990003753 Tax PIN/EH#: 5718-13-3343
Billed To: Kendra Rafie Subdivision Info: ,� `7�
Reference Name: Location/Address: Pine Forest Lane-27028
Proposed Facility Residence Property Size: .063 +acrers
ATC Number: 4214
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his 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 CO TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
/
Environmental Health Specialist's Signature: Date: �}
CERTIFICATE OF COMPLETION �
**NOTE** The issuance ofthis Certificate of Completion shall indicate the system described on Improvement/Operation 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: �� �
Environmental Health Specialist's Signature: f���/ Date: `7�'�--OIO
DCHD OS/99(Revised)
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, , DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
r � P.O.Boz 848/210 Hospital Street �b� �c5 S
, , Mocksville,NC 27028 �
(33G)751-87C,0
IMPROVEMENT/OPERATION PERMIT
Account #: 990003753 Tax PIN/EH#: 5718-13-3343
Billed To: Kendra Rafie Subdivision Info: � ��S
Reference Name: Location/Address: Pine Forest Lane-27028
Proposed Facility Residence Property Size: .063 +acrers
ATC Number: 4214
**NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a 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.
/1
Residential Specification: Building Type #People_� #Bedrooms�,� #Baths o`�`�J
Dishwasher: Garbage Disposal: ❑ Washing Machin� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply��/f/ Design Wastewater Flow(GPD) ��� Site: New� Repair 0
/ l�
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widttr�b Rock Depth��Linear Ft�
Other:
Required Site Modifications/Conditions:
11�1PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis '
system between 830 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33C)751-87G0.****
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Environmental Health Specialist's Signature: Date:
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DCHD OS/99(Revised) �
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� A1 ' 'ClUN f OR SITC CVALUllT10N/Ihf!'JIOVEhiCNT Pi:Tihi17&ATC
• e � � �� Davic County Health Department
�� • Environn�enta/Health 5ection
� P.O. Hox Ei4fl/210 Fiospa.Lal Straot
�;�,�:����G�� Mocksville, NC 2702d �
(336)751.-8760
**ItIPORTANT*** 7'I�IS APPLICATION CANNOT F3� PROCESSED V`�iJ�JJ ALL TH� RLQUIR�D
INFORi•S1ITION IS PROVIDLD. Rcfer to the INrOR2SATTON BULLETIN ior inatructionu.
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Namo Lo be Dilled � Contact Pcraon ,1 � ��lX i
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tdailing Addraan ��"_,.(,� ,/����� -�'QYeS'"1" �,(1 • Ifomo Plione l��ly� ���"�J
Cil:y/Stato/ZIP _�\��,IC.,)���II�F') ��11J�� IIuoino�n Phono ���1�� � `JI^1.�1C�'"I �
2. Namn on Pormit•/I�TC iL Ditferont tYian Abova ��i1!��,
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23ailin� AddroaccJ��� �'�1�� �� � �r� City/Stato/Zip ��� I1�( l�-vY �l � ��V ���� 1 1
3. Applica�ion Tor: �iL-c �valuation ❑ Improvement PeruiiL-/ATC �oth
h. syacc�n eo sc�vice: �J Jiou�re � 2dobile Home ❑ Du3ine3� I� TnduuL-ry ❑ Ot-2ier
5. Typa aynL•om roqua�L•ad:�Cl Conventional ❑ conventional modificd ❑ innovaCivo pacc;ePted
c. If�.Re�idenco: tl People _�_ # I3ecIroom� � 11 DaLhroomu �
L](IDi�hwa�her ❑Carbac�o Di�posal �Wa�hing 2daehino ❑Dasement/Plun�inc� ❑Danement/17o Plwnbing
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7. If IIussincau/InduaL•ry /Othor: vcrify typc ;) Peoplc 1! Sinkn
q Commodoa 11 Showoro �� Urinals If WaLor Cooloro
II' FOOD�ERVICE: �R Seato �uL-ima�ed S�TaLer U�sage (galiona per day)
o. 2ypo of wator aupply: ❑ CounL•y/CiEy f�4 j9ell ❑ CommuniL•y.
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9. po fou anticipato adJition� or cxp:insioc�s of ttic L•icilily tl�is system is i►itcudcd to scrvc? CJ 1'cs �No
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If�•cs,titi�hat typc?
***L1IPORT�IN1'y"**CLILNTSAIUST COdll'LCTET1fE XL•�)UIItED PROPLI27'Y lN1�UR11�IAT•►ort iiLQui.s•rcll 1
131'st.01�'. iiitl�cr a PI,AT or SI7'T•.PLAN�1fU.ST IlESU1iAfIT7'!iD by tlic clicnt with TIIIS APPLICATiON. �
1'roper(y llimci�sions: ' �Q � � 1VItITC DIItCCTIOi\S(fruni A•Iodcsvillc)(u PIiO!'Istt'1'1':
r:�.orr,«rirr: ����'I 1� I ����-� � I I�� ��5� i �� I������� iU i'n �
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I'roperly Address: Road Naiiic�l�X. �� �S� �,��1� ����� GI� 1��1�I� ��('�I���r}'I1,��
ctty�z;p I'�D(`,1�)�(�.�-C��. � ►��SS '�_� �-u F�a,� .�`�l 1 Y r'1 Q�_
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ICiu a Sul��liti�isioli providc ilitorri�a(ion,as follosa�0 �1(,�' �� ��'��ii� ��`�. `2i"�(� ��(� (`�•�
rr:�,»�: �1.��i��� i-f��t���1 ��1� �C ��1 1(,n��11 u r�+, I
�,�„ o s �t��,� Se v
Scctiou: I3loclt: Lot: llaic ]�omc corucrs Ilaggcd:
`�(l�. ��r S� L�'j� �,Di+(�t-
'I'lris is to ccr[i1'y tli:tt tlic i►ifoi•m1�lUI1 J)I•ovidcJ is coi•rcct to [Iic best of iiiy I:►io�vlcdgc. I undci•st�i�d tli;it ar�y per>>'��5��� ��`����
issucd Iicrc:iflc�'71'C SUv)CCI IO SIISf)ClIS10I1 Ol'I'CYOC�t10i1�lI�I1C S1�C j)I�I15 OI'ltlfCJl(IC(I lISC CI1:1I1�C�UI•if tlic ilifoi•luation j�� C+(�}�j
subuiit�ccl iii (liis applicatio�i is f�lsificd or cliai��cd. I,also, «�ulcrs[cr��d tlrail rrur respo�rsiLlc f��l•a!!clur�blcs i�rcrrrr��d fr•v»r --
dris«pplicn�iar. I,ticrcby,biti•c conscii� ta tlic Autl�orizcd Rcpreset�t:ititi�c oC tl�c D���i ouiit}�Ilcal li cpai•tU�cut , �����������
to cntcr upun a�ovc dcscribcd pl•opcc•ty�focatcd in Davic County:t�id otirncd by �� �l (' �' `((' ( �1 G 1''C���'{-�y
IO COIICIUCI :III IL`S�JIIb'Il1'OCC(Ii11•cs as ncccssac•y�to dctcrminc thc silc suit�bi it��. , (S ������,� ..n,�
Di�'I'� � �� � 11� SIG1\'r1I'URL � '� ',� � f � C�- ��
TIIIS AItI;A AIAI'B�US�ll rOR DItA1YING YOUR SITL PLAN(IncIudc aIl of(lic folIotivinb: L�islin�;ancl proposcJ`r�'t�L� � Z
property Iii�cs anJ diinensio»s, structures, scibacics, aCl(I SC�fIC IOC:1fI0IlS�. � ('��j�'�'��!�j��)
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C�,,,,,�- � �1`" Ja`'''�Q-�� Sitc 12cvisit Cl�ai•�;c
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Clicrit NoliC�atioii Dalc.
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Rcti�iscd llCII (US/03 � � t - �� Invoicc No.
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PLAT OF SURVE.Y FOR : CertiFicote of orr�ershlp nnd dedicntlon
�ENDRA 'No Approval Required by the Davie County Plnnning DepartMent'
I (Ve) lwreby certlfy thut I nn C�e nre> the owner Cs) of the property
RAFIE descrlbed hereon, •Nch is tocnted In the submvlslon jurisdictlon of Dnvle
, Co�mty nnd thnt [ hereby ndopt tNs subdHlsion pinn ritfi ny free consent,
established �w+ bu�ding setbnck lines nnd dedknte nll streets <roads>,
nlleys, walks, pnrks nnd other sttes nnd ensenents to public ar prlvnte Ptnnning DireCtOr' Date
CALAHAN TOWNSHIP, DAVIE COUNTY, N.C. use ns noted.
AUGUST 17, 2004 SCALE: 1' = 40'
40 0 40 80 120
Date O�mer (s)
GRAPHIC SCAI.F' - FEET Filed this _day of 2005.
CURRENT SURVEYING & MAPPING, P.A. REVIEW ❑FFICER'S CERTIFICATE at and recorded in Plnt Bk. Pg.
1353 BRUSITY MOUNTAIN ROAD I, , Review Officer of Dnvie County,
WILKES80R0, N.C. 28697 North Cnrolina certify that the r�ap or plat to which this
RICHARD C. CURRENT, REG. NO. L-756 certificntion is nttached Meets atl stntutory requirer�ents
for recording. Register of Deeds
�r iv�enm c�oa n��s surmY aa n+E PNtT OF 1FIE SURVEYOR
IS SOLELY 70 KENA2A RAFIE �
• Review �fficer 1/2' �T'e �ine)
C�IRRENT TAX RECORDS USED TO iDENTIFY N g2� �W
" ADJOtNiNG PROPERTY OWNERS. SURVEY Pipe-�♦ 42'00
PERFORMED WITHOUT A TITLE REPORT, WHICH ,f----., 1/Z'
MAY REVfAL ADDITIONAL CONVEYANCES, Date IS�00
/ J Rebar
RIGHTS-OF-WAY, EASEMENTS, OR OTHER �
RESTRICTIONS NOT SHOWN. ' '
NI]TE + SURVEY IS ❑VER 2,000' FROM ANY PUBLISHED I
N.C. H❑RIZ�NTA� GROUND CDNTROL � � N�TE � R/W IS NAMED
NOTE � THIS PR�PERTY IS NOT SHOWN WITHIN THE FL��D PLAIN. � o ' PINE FC]REST LANE _ _
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Bk, 91, Pg. 34 J � � a
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Existing 30' R/W
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\��S 6�`$1, ��'J� o / Pg. 641
IS 44`E 1 a �, o' ^ .
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Bk. 91, Pg, 34 � �I � � I '
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By Coordinate Cor�putation � � ZONED RA
Ref, Bk, 91, Pg. 34 � I ' � Cliftor� Cooper
(a portion of) � __ _ __-
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Bk, 91, Pg. 34 •S�
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+ See D,�eed Ek, 105,
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SETBACK LINES �
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SIDE 15' •:��N s'�'s'����+ f `0
, REAR 30' •:• -Q�oFE ioti9c: y� ��\ a, �-
: SEAL � \ A
' L-756 ? W O �
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���nw��� \
, VICINITY SKETCH \ \
I, Rlchnrd C. Cv�rent, Professbnnl Land Surveyor No. L-756, Certlfy
thnt tNs pint Is of a survey of nnother cutegory, such as the W -
NOT T❑ SCALE recoribVwtion oP extstk�g parcets, n co�w�t-ordered survey, or � �
other exceptlon to the definitbn of n s .
-� � See Bk. 91, P 34 for
" .o � r�'� R/W fror� property
' °i ° to SR 1153 <Shad
�
" Rlchard C. urrent, Professlonal Lnnd Surveyor, No. L-756 � � rl y LEGEND .
Knoll Lane)
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�* "` 1-1/4' • Iron found
SF� � CERTIFICATE OF SURVEY AND ACCURACY Pipe O Calculated POIt1t
` � SITE I, Rkhnrd C. Currmt, Professbnnl Land Surveyor, certffy tho.t thls ncp rns c�^o�� ♦ Power PO�E'
fron nn actuul sur ey nade under ny supervlsfon <deed descriptlon recorded I� � rJ�B' Rebar 52't
; � Bk.�_, PQ.3� , etc., Cother> that the bour�daries not surveyed nre cicwrty ,
' 6� kwYcnt�d ss b-nw� Fron ir►for�►ntion found in Bk. — . Pp� thnt the rnlb
_ �p � K"� �`� of preci�or► ns celculoted Is U u'_�WTthat this nnp ■os prepored In uccordunce Mlth • •
�'^ � G.S. 47-30 ns n�ended Vitness ny orVpMal sler�ature, registratfon nunber nnd seui tWs
.":a � �° �_.doy of A.D. 200 _
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. , � Cv�r C . -
i; I�l Rd
• Rfchnrd C. C ent, Professlonnl �n►,a s y«�, �. �-�sb Co ri ht C Current Surve �n & Ma in P.A, Au ust 17, 20D4 �
JOB # D0502 ' py g � y 9 . PP 9� 9
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� ' , � ' DAVIE COUNTY HEALTH DEPARTMENT
, � � ' � Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003753 Tax PIN/EH#: 5718-13-3343
Billed To: Kendra Rafie Subdivision Info:
Reference Name: Location/Address: Pine Forest Lane-�i���/
y� ��
Proposed Facility: Residence Property Size: .063 +acrers 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 osition .L
Slope%
HORIZON I DEPTH J `' �'
Texture grou L� C L
Consistence � l' y�/�
Structure
Mineralo ,`
HORIZON II DEPTH ��`� � 'c
Texture ou �
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: GC � EVALUATION BY: �r�� /1
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
t
REMARKS:
LEGEND
I.�ndsca�e Position
R-Ridge S -Shoulder L-Lineaz slope FS -Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope
T�Ctur.�
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
.ON�iST .N .
��415�
VFR-Very friable FR-Friable FI-Firm VFT-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
, r, ,r
SC -Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky �
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogv
1:1,2:1,Mixed
1Y0�
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 DCHD OS/OS(Revised)
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