295 Main Church Road Lot 2 Plk--
` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
Account #: 990003603 Tax PIN/EH#: 5749-09-2174.01 RB
Billed To: Richard Bell Subdivision Info: Potters Field Estates Lot#0$
Reference Name: Location/Address: Main Church Road-27028
Proposed Facility Residence Property Size: see plat
ATC Number: 4230
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED 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 CONSTRUCTION IS,VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date:
CERTIFICAT O OMPLETION
**NOTE** The issuance of this Certificate ofCompletio hall i 'tate a system described on Improvement/Operation Permit
has been installed in compliance with Article 11 G.S. ap 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken s a gu nt that the system will function satisfactorily for any
given period of time.
1
i
tU
Septic System Installed By: 404
Environmental Health Specialist's Signature: / Date: f— S
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
' - Environmental Health Section
P.O.Boa 848/210 Hospital Street / v / 6
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990003603 Tax PIN/EH#: 5749-09-2174.01 RB
Billed To: Richard Belt Subdivision Info: Potters Field Estates Lot#01
Reference Name: Location/Address: Main Church Road-27028
Proposed Facility Residence Property Size: see plat
ATC Number: 4230
**NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of 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: J2( Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industtr
1rial13
Si
Lot Size Type Water Supply k:6 Design Wastewater Flow(GPD) � te: New Repair❑
System Specifications: Tank Size, AL. Pump Tank GAL. Trench Width S�'/Rock Depth - ,Linear F637w)
Other:
As stated in 15A NCAC 18A.19690
acceptcd Systems may also be u
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative oft avie County Health Department for final inspection of this
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m. the d y of installation. Telephone#is(336)751-8760.****
Environmental Health Specialist's Signature: ►'�7 ` / Date: A)&
DCHD 05/99(Revised)
D �
.. LE
M'I'LI N FOR SITE[VALUATION/Ih1PItOVL•1tiiL•NT POCT 6&ATC
r Davie County Health Department
• �1 ..
Environmental Health Section
K,--�" P O. Box 848/210 Hospital Stre
✓R N �tl Mocksville, NC 27028
(336)751•-8760 €fRl1l
***IFIPORTIINT*** TRIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMTION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
:R1. Name to be Billed ;G1 C.I UA �ti--, ( Contact Person "P C g•aI//
Mailing Address �ACk V11h'L "u(kr' oma Phone 33 Y
City/State/ZIP (1; Btu in ss Phone 3'3 (o a7 y U
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation Improvement Permit/ATC ❑ Both
a. System to service: [douse ❑ Mobile Homo ❑ Business ❑ Industry ❑ Other
S. Typo system requested: ❑ Conventional ❑ conventional modified ❑ innovative r3accepted
6. If _Rosidence: it People -F # Bedrooms 3 it Bathrooms
[]Dishwasher ❑aarbago Disposal MWashing Machine Mas amen t/Plumbing MBaaemont/1to Plumbing •
7. If Business/Industry /Other: verify type # People # Sinks
# Commodos It Showers # Urinals # Water Coolors
IF FOODSERVICE: ff Seats Estimated Water Usage (gallons par day)
8. Typo of water supply: 63 County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes M-90
If yes,what type?
***1AfPOR7ANP**CLIENTS 111USTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
IIEL01V. Eithcr n PLAT or SITE PLAN AMST RESURMITTl:'D by the client with THIS APPLICATION.
Property Dimensions: rte/ — WRITE DIRECTIONS(from Modavilte)to PROPERTY:'
Tax Office I'IN:
Property Address: Road Name/AC.'-'-1 CI.14
City/Zip
If in a Subdivision provide information,as follows:
Naine: ���``� t f s �0'
Section: Block: Lot: aZ Date lnonne corners flagged: 7- 30- 01
This Is to certify that the information provided is correct to the best of Iny knowledge. I understand that any permits)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this applicitio_n is falsified or changed. I,also,understand that I aa1 responsible for all charges incurred froom
this application. I,Inereby,give consent to the Authorized Representative of the Davie County Ilealtln Departnient
to enter upon above described property located in Davie County and otivned.by
to conduct all testing procedures as necessary to determine the site suitability.
•DATE SIGNATURE
TRIS AREA MAY BE USED FOR DRANVING YOUR SITE.PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site IZcvisit Charge
/ Datc(s):
v— /`�` � " Client Notification Date:
7z
EI-IS:
j,/ 0 3
Sign given C '. Account No.
Revised DCIID(05103 Invoice No. 7
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT
Davie County Health Department
.Environmental Health Section 1.1" APR ,
P.O. Box 848/210 Hospital Street 6 ZOOS
Mocksville, NC 27028
(336)751-8760 EWIRONMENTALHEgLTH
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUI
INFORMATION IS PROOnVIDED. Refer to the INFORMATION BULLETIN for innstructions.
1. Name to be Billed /� l�i-1�ri� 1/J r �l-L�- Contact Person let)- Ce L STJ 0 C
'LCCA G}14 c,19J c GCLL
Mailing Address __ /► L. LA iJ r fl�o a ��j�- �G�j 2— (fj L''�
City/State/ZIP j, L�C�.S lr�l , 1U C, Z�OZB Business Phone �� 8 - Lf 7 33
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: .a Site Evaluation ❑ Improvement Permit/ATC ❑ Both L�'
4. System to Service: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
S. Typo system requested: (J' Conventional ❑ conventional modified ❑ innovative
6. if Residence: # People Ji- # Bedrooms It Bathrooms 2 z
ODishwasher ❑Garbage Disposal 131ashing Machine I1iasement/Plumbing ❑Basemont/No Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: ## Seats Estimated Water Usage (gallons per day)
8. Type of water supply: E3County/City El/well ❑ Community
9. Do you anticipate additions or expansions of tile facility this system is intended to serve? ❑Yes ❑No _
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTCD by the client {Vial TIIIS APPLICATION.
C t -
Property Dimensions: S 0- (A T WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: #t? 5`7 q9 09 2 )'-JLI 1 S 8 -rO ✓ A I,1 C8 9�
. 1
Property Address: Road Name yyt.4 rN C14VA r-H r-A-r
City/Zip ✓J10 c.ux/1 t_L.N= I I\1 L ) >"►I u- -'k u N t__1=1--T
• 2'7 OZt�i
If in a Subdivision provide information,as follows:
Name: �O -r1c)2 S F- )L L L's 14 Tc
Section: Block: Lot: 12 Date ]ionic corners flagged: - 3 ) - O S
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 c]iange,or if the Information
fi
submitted In this application is falsied or changed. I,also,understand that I am responsible fur all charges incurred front
this applicalion, I,hereby,give consent to the Autliorized Representative of the Davie County I-Icaltli Department
to enter upon above described property located in Davie County and owned by 41c:k44t210
to conduct all testing procedures as necessary to determine•the site fiitability.
nr /
DATE �l tl5 SIGNATURE,( ;
TIIIS 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).
Site Revisit Charge
Datc(s):
Client Notification Date:
EIIS:
Sign given Account No. D
Revised DCIID(05/03 Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
A.ppount #: 990003603 Tax PIN/EH#: 5749-09-2174.02 RB
Billed To:- Richard Bell Subdivision Info: Potters Field Estates Lot#02
Reference Name: Location/Address: Main Church Ro - 8
Proposed Faeil.ity: Residence Property Size: see plat Date Evaluated:
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit L/ Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH 41-!, �.
Texture groupt
Consistence /
Structure
Mineralogy -
HORIZON II DEPTH
Texture group
Consistence
Structure / G
Mineralogy .'
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 RAT
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
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
T xtur
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
ois
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
of
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
ICI ID 05/99(Revised)
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:::C:CCC::C:CCC9:9:C:9999:99MEMO 9■
i.George Revert 9tons,PreNwelenel Land Surveyor.L-3162.c@r Wy to one �E'
I declare that on /0 - O 1 . 2005 d the fabeing as Indicated thus, er This property is
we surveyed the property shown on ® Notes: streets and assessments, If any an the same mayapappear of
°. That tide pbh is d a survey tlwt r ad w a eubrAd elon d lend wWOn
this plot: the aria d a dowdy or rmaddieeft that haw an ordinaries etrd 1. Zoning: R/A record M the odYice o4 the Register of Deeds, Clark of Court,
"4" 'pO1°�'°f len# 2. Minimum Building Setbacks: Town or county Tax Office or which may have been aequked by
g prescriptive use and were nat vb&e at the time of this
b. That this plot is of a survey that Is t000tsd in such porton of a Front: 40'
survey. This survey is subject to any toots that may be
aonrdy or nrxiaipodty that is unregulated an to an ormrrano. Rear 30' disclosed by a full and accurate this search, NOT furnished Aloin
that r"9'111011's parcele of load; Side: 15' as of this date.
Road
.�
C. That this pat le d a surrey a on adding para«or porosle Side Adjacent to a Street: 25' SR 14M '
CAR of lens: 3. All utilities shall be installed underground ^�
4. All Lots shall be nerved b private septic systems rnie mop or 3rvwing and P« +(r) ��
�tsESS%•.•�/,9 a. net rile pat le d a survey d arold,.r oadegory,wd,as the y P P Ys Thisdocmenta err w ed a accompanying
•��, �,•.•• recombination a eaistkg pof eia,i cion;cowardsred survey or other thereon and no ofti rations or use by others
.Q �i ssceptla+b the dafYiton d wvaion:
is permitted unless authorized by Stone Lurid Surveying Co.
a. Thd the Idor"ichw available to fhb eurveyer Ie such flat I am
L-3162 � tv � weede to main a dsbrmlast d my tion to ore beprofessional Certified copies of this survey map will not be Issued
obNky as to prowWwe oor"ved In(a)through(d)abase beyond ninety(90) doge of the origins! survey date.
�Cn SVR cj George R. Stone Map not for recordation.
` ROBER'( g Precision 1:10.000+ F
3/4" UP Fnd Land Surveyor, L-3162 Vicinity Mop (Not to Scale)
PB 8 0 PG 198
to
0 0
I
"NATURES PLACE" "NATURE'S PLACE'
PB80PG 113 ( PB80PG 113
Q 4Cb
I�
Planted Stone Fnd L-4 -. qq V4,
1 2" EIR Fnd L-5 y
o / ro
All A,
'
a / I
1 2" EIR Fnd \� /
16
20.9'
"FARMLAND ACRES" F
Section 4 1.054 Acres +/- 091
PB 5 0 PG 201 (by coordinate computation) Q.
IRS 187.9
- /21,
A- � N
Q �ry J
(0O
Planted 1/2" EIR Fnd
ca
- - - /
Stone Fnd
_ L-10
T-Bar w/cap Fnd L-2 - . --- ---
- _
T-Bar w/cap Fnd / -�
Tax Lot 16
I Tax Map G-5 — Existing10'+ Gravel Drive
n/f John Lee Bowles /
Note: Grovel Drive Crosses �
and wife Property Line Tax Lot 17 Q-
Pauline M. BowlesTax MoG-5
DB 66 O PG 256 I n/f Ann Wall Sain, �X
R/W - Right-of-Way LEGEND FC - Face of Curb Dorothy Wall Short,
Potay Wall Short, `
UP — Existing Iron Pipe BoC — Bock of Curb /
PIR Poststing Iron Rebar LP - Li a I do James Hayward Wall, Jr. /�\
Light PortPROPERTY LINE CALL TABLE TIE 'LINE CALL TABLE D8 168 O PG 764
CM - Concrete Monument MH - Mon Hole /
IRS - Iron R�r Set CH - Chord Distance Site Plan for.
P/L - Property Line P/0 - Part of COURSE BEARING DISTANCE COURSE BEARING DISTANCE
C/A - Controlled Access DB - Deed Bae°`` Richard Bel l
CP - Concrete Pipe PB - Pia Book L-1 S 07028'50'W 281.52' T-1 S 12°10'24"W 24.73'
CMP - Corrugated Metol P,Pe RB - Record Book .
CPP-corrogoted Pkxrtic Pipe PG - P L-2 S 07036'26"W 520.08 T-2 S 58018'23"E 24.75
-F- too Year Food Boundary CS - CTh Basin L-3 N 89°03'27'W 277.24' T-3 S 07033'46"W 32.73'
-o- overhead utilities -S- Sewer Line L-4 N 03.00'32"E 528.52' T-4 N 89017'31"W 40.68' Lot 2
-x- Fence WM – water Meter "POTTERS FIELD ESTATES"
Fnd - Found WV - Water valve L-5 N 03000'32"E 459.06' T-5 S 86°23'17"E 200.11'
n/f - Now or Formerly BM - Bench Mark L-6 S 60°32'05"E 117.28' T-6 S 03004'27"W 41.74'
NMP - Nonmanumented Point TOM - Temporary Bench Mark L-7 S 59018'51"E 118.57' T-7 S 03°26'08"W 5.10' Plat Book 8 0 Page 198
CL - Cents' Line RRS - Rail Roodike
EP - Edge of Pavement CIV - Cabls TelevisionPedestal L-8 S 58°25'48"E 121.43' 1.054 Acres +/- by coordinate computation
TP - Trlsphone Pedestal ETB - Electric Transformer Box L-9 S 58.21'37"E 27.40' SCALE Fi1P
TONMSCOUNTY SLATE DATE-w- water line CO - Sanitary Sewer aeon Out
(NTS) Not to Scale
L-10 S 07028'50'W 292.70' 1" 60' Mocksville Davie North Carolina 10-01-2005
-
L-11 S 07036'26"W 150.00'
60 0 60 120 180 L-12 N 59°20'21'vW 106.15' Stone Land Surveying L-13 N 59'20'21"W 106.00' y.n9 Com an
P y Jur No.
L-14 N 59020'21'"* 106.00' SC,DB George Robert Stone, PLS L-3162 1205-2
GRAPHIC SCALE — FEET L-15 N 05.50'03"E 450.67
MAPPED: 113 Drum Lane Phone ',336) 998-4733 MAP NO.
L-16 N 04024'1 5"E 456.14' GRS
MorksAle, N.C. 2'029 1205-2