421 Potts Rd Davie County,NC Tax Parcel Report Tuesday,November 8, 2016
5
I t
' , I
Jf5 II
t
� ' I� /-429 S
N'. eo
423 ' I-Z427 't
f!t Fjf
f t j f
i•� i
415 _ t.5
`�-'--- -� 421
k
r . f
413 0 C _�------------115
Qr --
__
1N & OLITLN
WARNING: THIS IS NOT A SURVEY
-LL
w Parcel Information
Parcel Number: F800000144 Township: Shady Grove
NCPIN Number:' 5880177669 Municipality:
Account Number::-- 6608580 Census Tract: 37059-803
Listed Owner:1: BEVERLY MARKA Voting Precinct: EAST SHADY GROVE
Mailing Address L• 421 POTTS ROAD Planning Jurisdiction: Davie County
City: - ADVANCE - Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27006-7873 Voluntary Ag.District: No
Legal Description: LOT 1 MARK BEVERLY PROP:, Fire Response District: ADVANCE
Assessed Acreage: 1.07 Elementary School Zone: SHADY GROVE
Deed Date: 8/2007 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 007250035 Soil Types: PcB2,PcC2
Plat Book: 0008 Flood Zone:
Plat Page: 231 Watershed Overlay: DAVIE COUNTY
Building Value: 135250.00 Outbuilding&Extra 0.00
Freatures Value:
Land Value: 17780.00 Total Market Value: 153030.00
Total Assessed Value: 153030.00
All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, 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
SOU t,SC NC or arising out of the use or Inability to use the GIS data provided by this website.
AUTHOZATION 190: 131 I DAVIE COUNTY HEALTH DEPARTMENT Z l/ald
' Environmental Health Section PROPERTY INFORMATION
Pelmittee's P.O.Box 848
Name.:. -MA " Mocksville,NC 27028 Subdivision Name:
/ �/-t � /d C:i ./ Phone#:704-634-8760 --
Directions to property: O ( Section: Lot:
AUTHORIZATION FOR-
WASTEWATER Office ffice :#-�-Ied
SYSTEM CONSTRUCTION PIN
w �
CC= d N I "YI q Road Name: �I` Zip: of
**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 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
i ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST `DATE ISSUED
� s( -= i -�_�-Y -.,.ar-• a .i.y.,i�ti. .or.t yd4 ff2., =a .•_ .. , ,_ - - ,,. ,.
>itteo
DAVIE COUNTY HEALTH DEPARTMENTIMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
1'`I'
Subdivision Name:
471
x
Directions tt)property CJ �` may' ' r`` Section: Lot:
IMPROVEMENT )
.` PERMIT Tax Office PIN:# <' -
'`^C% YI Iw Yl Road Name: ' �i Zip: aye ,
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation 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/mstallation 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)
f7
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
,,ma''` '`r• 1 r ' `T�'1 J ""/,s` f PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
/' INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE I� #BEDROOMS l? #BATHS 42 #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE „ TYPE WATER SUPPLY 6 DESIGN WASTEWATER FLOW(GPD) 6 NEW SITES REPAIR SrrE
SYSTEM SPECIFICATIONS: TANK SIZE'.�GAL. PUMP TANK GAL. TRENCH WIDTHS ROCK DEPTH J.2 _ LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
V�
IP ,q�
"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
SYSTEM INSTALLED BY:
wo ems,
AUTHORIZATION NO. / OPERATION PERMIT BY: DATE: v
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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)
tilr'.+,' .M+raslUU��''Sr
,} ti
dry! �- ) ,APPLICATION FOR SITE EVALUATION/IWROVEME, ,
�,1,,1"fY �. 4 .. .. .. r''.r(",
+Ir'
Davie County health "k4�''a ,V
,�5}}yy,.•w`•' �•�� �: Environmental Health Seo { ,: r ,r�J„ ' .'�,i.ri� t•
ctiiK2�^;/.1997 .��
� �y7C3,k, P.O.Box 848
tr v't r�f S ' t r+•
d4c�u K tai{ (, Mocksville NC 27028 ` "-'t
I';:r ',', +7 44 ,, tv v /.Ir�{1��] �tf dr4.Nr Jkiyt;
..:•(704) 634-8760 .. '+. *'Ii rt l (j, r k ,�ya(;y 1<e�:ila urafal
f ( [r a8 T�` f y1f+Ji 4 i.y ^" IJ' T' t' ! _ tM.•lyw s ti. -.r Jt„rn; Jj'itr j,t+u t r(r
• �gt+� r, t.� .�SeG til < r+ o J!F C t' i. �:y ,.I .;,,. w,:. ,nl�f`•{+I•�,..X,';MJ ar�a,Gxriw N'Ki,Y.'`$t'i 3•L��iYA�„`�i idnc� 7
Il1� )RTANT:�'T `r THIS APPLICATION-CANNOT.-BE PROJCESSED,.UNLESS.ALEt� `r
f'�:ka.., pr�''`N;mY.ueti•to'r�re^rB.s 1 ai+`ll'er dr`s' { !,,'/�t A (ti''�� .. I.-P• RO �� rEREQ
,I;ty♦�ir!�-a',f.€l r..}V,b.'�N1it.7.ll4a,r S�f�h3"r�5 G6aµwtt�'y F}a rf�
r
MFi�
tTHE RM „
AF
arg !E�V SLY Contact Person' �
y+'�k rrrr,: r ,:' F'u�'+:.r t +r� rt{r' ' nid '�'",�,hL )'"✓r3N �+"�+:t j �
ad^� 3'af/i+63 C r
Maiting Ad
"r dress ; 8
• { , It t y>r i J t,t tw^+ Si�csll ylt x•lyd�Jr }t, ' Ft1 + MIF
ty 'at,ep`t r'� ►..-- Q-m 11�C: '71 � Business
t i ��'��rs a�tt 'v's,% �t:r,�w ., !iy 4rn..s:: \;� sk7 inr�d-�-d�'}'t,7`�9i�'S lyti,r•rf 5�'.ti�Tls"�ri t l�.
� (:"tz�r' r r^^�,}, ', i - : l ., " },J p t+.•,1 i ii- '�"
2., ame o&.Pernut/ATC if Different than Above
' �z•,,,�,i3�H}4,rL 7$tyr l ra i - r r. , `t +rt �lk�r! TM iy.f �� Pj
:y " i �,� 'ft2��..,'A'9,W,yf'' r• ,ti# + "tr t, ✓ •''r .�i�tl' fl!, . �Kft�`+'�1(1raAk$irmirt{y, A•ttn 'jFt '
,lviailing�ddress ° " ' ,r :J. ✓ �' City/State/Zrp
1-g,
j'i 1
� Kr�tll�lr�A
IWi 1.' rt , ! d + 1344 ti'+!,
. A pL� t s n:For [Site Evaluation Improvement Permit&ATC [ ]Both �rYl r F t
stern�y,o Servye iY[,]House �j�/t Mo 11 Home ,'[ ]Business
'. [. ]Industry
���,f+' .��"ti�ya.;�,r 1'Y., •_, i 'S s}� �rt.j�.�F&NS�f'h'�*W'k�=T�i'�li"{t"��r��}'l.+� y�•S',�`�.ti,�
`#,People #Bedrooms• #Bathrooms [ ]Dishwasher[ ]Garbage Disposal %-,g-
e:,
w�r
5. If Residerr £ ra -AWK.
,, 5t+•Y^7i }
h.a4 fn'#, r Jt. r 1? •did( •'r h h N{{�h.d'Y,'r W,t i '�i'.'Slr`Jwi.Jlti ,%Y vi
�f .N•„ rY$,y'},j'S A45.(,}.srwj; , r f ,:' Xr. �• t 2 f•I(D
ash ng Machiner [ ]rBasement/Plumbing [:.]Basement/No Plumbing f x ; '+r ,+i S�rar,Mpr- '' +["r��"r} r _; t1 a�' t
i }}!' P 1 ' ' rYt( }rKro•''4y71L-i IN,.(" 1��Y^'•r 4 fh 3 di
.� J'ssT��✓1�L'k;�,Gr},'�7 tl K' ' :.. r: � , 1�w ,awl 15i�r:Ni ttt}.�h•� �'•i 17:lr rFff �S�i1,y�„A(1 �rr.�l.it •.
0 ..h r w #People ' #Sinks' t y, .,,#Commodes, =`r�
r a:t }t.
1.
a. usin„�s/Other+Specrfy.,type r
,y t + 1t+.,' y(,3 hrx-^�'YYCrr� 1':- Iti{'fc." !
h ?S �'YFy^i+f'Y.�'�.(.Urt$�NI��'.f�!'•.i i\F° ' + l,t .. �. rrti,
Vitt e + .I. (')Y ^gk i '�r• „f I�,y”jl. tr
#Sh�ers i 't #�Unnals #Water Coolers ;
� f'• � /rr4. i yyA.'Y':rrN k.;,.Sr/•V ':.r l 3:., .i! kl T" Vhl'f,�44,, t•F(LaY!�r j.-ie'i�Fl,'tM i rA,1C , \ •
y,. tyly}S�w. h�� +ye,,kt, t! n' , � t•t � r T 3 kY y y a'Q '�.L.��,,,,��,� 'S f
4"SY. t , � X °-^ + rW .53{....#„ 7tY�t�";.,J7�M�i.•.�`lt¢>< :1+• �
A oodservice' #�,Seatsk �„ y� ` Estunated Water Usage:(gallons per�day) f
�yy iy
F tr a+r *t
Well [ ]Community,
1,watrerS,supply LTJ k-;0 htiwt, ..k�4"iixh3j ':rNy'4,rkC` d ,�S�j ra( •i, 7'
8 Do ,a iticipate'additions'or expansions of the facility this system js intended to serve?[ ]Yes; [ ]tNo r} <ir y ( IC .
'JN Yd Cf�r{i'ti��/�#iivr<,�4�}t �r !..4-34
l` N a FtY•J Pe?r~2'
y�
P1:AT 'Oft I SZ ZEPLAN� ME
%PROPERTY
INFO ORMATION REQUIRED ***IMPpRTANT*** \OF THE PROPERTY�tMUST�BB '
„' '' /1 '}�J/� (�[t , fr - SUBMITTED WITHa 'APPEICAT�IyOI�i:
We. ��f'✓^�"�) � "sti..Z':'.�'�atr'i>•.Sb/I+��rr7?'tlt Y�N, �r}y'��.�'�,�'�!f��,�,tt•���t}iK;�k� � G
-'t � i 4 ,r^arrXr�i�'th{�Fi�c`eri{''X}.. l t ,",,� t•r.• :.
f-I-cr-eS WRITE:DIRECTIONS,(from �cic vrlle)pTOPItOP: R
P..pens Dimensions
,i?�,ct"redsl, M{ntt�t�!yiI*1�taattl�TIr,ArMyt�+s+O' trOi .i;6t/ ,',••/�omi+Pic's::' .:i:�.:.. O r ! �
i�/(rr/�CA��;�f4!tixlC�<,.F{S�•,1'1°EyNrJ'4Fjs�x i7�ffi4 wx[a\7 n{tS(c'rMs#I
fl ,4rNW "ddt
gRoade ^
`ddress >rto �
`
q rsCrtyd<ipFth°rc,aNCxy}.a'!�.y
i rP
rr?i yw S, A, n.
S},+,,*Ir i yr+.F.t;u int.{.x r r';' ; ,.k r w r'' y nJ'j. , a.Y I !i.ta +i+ ri✓.19
i
�fiin\Sub`division prove a information,as follows _
t +. •- 1 , ' ,9 l w t tr„I+St y J l Ct r i'} � ,
Td t J t 'H r. W it 1s^
.,� �kF"+�� ,r7 1�",� r•r rf 1 r �,r. 1 • '4l, 1 t< Q �� �.r.
sa Name E- { ' � ��• ,,, -I "ti .r,...^rr lit a F:
t? k Ara lAr.�f,r S ,it er,, T,, ' :^... 1 r" :F r� •TJrtXY `ws y`tV'' �4�ys5{�i
1 .Sect}mpl''t'.}3r3 .a„a�LL.7t1�I I c ti' �`tLVt# "� -! �; r .(';•ar...htl Maya.,ly�r s�5. 5�+ygj�y. �r�y�yp
-di�f6, ' ,r r„"fil�d•`,!(,,.G'1'Jr�••,,'... s + t 4+ .:,s i 1 Ir, :r�• ;C r::.S.'liy yF�Y��'Ti{thr3i�IPtRt�if�X,I�.iyWr+,:ti:�W�`Y.iKitll
tr�J,Q3,�( ti +, ,: .t P:. y ', +' rV!y,�'� 1'rt4��fJl «�}k'{✓�(}!j�, p
r r r,; \ .•e.Yr It7�] ,I ..•'r }F of »L.ti)i. !hirF.,NSd1!, "...� . MS'ti7H{' 4.�' Yn
's 's to”certify.that;the`iriformation'' royided is.correct to the besfrT� f}'.my.knowledge I understand that any,.;permrt(s) Issued!,!1C
aze
lu;n Pd.t ?a� ����Yr 'F G"^° !h�' �f3:f,
„u�:Sf;ry.tit ra F.,r, ,r4 :• J IB wp fat { S.
sub'ect to ws ensionron't"evocation,if the site'plans or intended use change,or if the mfonnatron submrttedtin ttus.applicatron�ys'falsified or
.� p.-fit 1Y irJ�,vsi ty^^t�,. f" ':.!+ ! !nr '`''$ ' 0,
g
�. +F..Tn`•'q��Sh�,'I";��,}.,44l,tyt+,l;l�'tt+' "f F•�..G ;.,•`..:.:ti .e .f;'. , ..,�.;.,rf. . �i'�j�'+17
chan ed. ;a1so;unyderstand�that;I amfresponsible foe all charges:�ncucred from this application-I; hereby;�givepc°Ween r too thcAuthorized
.g '� , i.. 5 t...f r •�; " ,' 5, `.4yt w s + ;'.E.:ss;,I , rn fSM)•^;•,, �' �3
' 1 e resentative of,the"DaV er,County,Healttt'.Department to enter�u fin above described:propertyhlocated,in�Davie County a owned . t"
F r J, y to >
4! Ikt S/ - J,iIC. .(' r•+,, ..<:,o,,,l\;,rltkT,'.r'"F §.:f r+7,Y�{ty� y t . .,, '(r 't.r
li ;,,,;;.tt i�6r, ..+), r„•r r, to conduct all testing procedures as necessaryto determineh the site�))suitab�
v 5 r:�.. ,� Ji}�F,: n�! Ar ti.• r :. :;.. +z..Y:. ',zN�! s (4th +tl h' {"P� 37'ji'$a �{nisi!r� •}f I+ii 'yrs II + M.
DAZ rZ SIGNATURE .
.�'
n
F. ..I.l�. . zj
��•1Tv�53�5 �r 4
Revised>CFiT'(06=9�'r MEN
MRA
T. t'
iryt++h �fFX _ rFF FJi FA�f'.A'•1N�4 USEb FOlt DRAIVINC7I OUR
A .M yRrYi, M ! d..r r .4. 1 4 rllil r l�, 0 J hrr r•'� ,4,�` }I, tf.f!M1y }�
1 t .k•!FIfCa4'( Yay}�r.'1\ Ic. '.,:'} ///`)- a.i,.�+. 1�. ,t.t.. {�-'h.r r �ny} M;f ,,,rrJ r.�{i r..
b .'••L:IPity, `(•�ar 4lft t,t:!a x.9.i r , ►I f� P/:%�./ � a 'iLnrr,� r•i ti; 1." .�; �4 rib"SYS�:.rh -R�fymt ��.� � 'i: rtt.
4�,,`.?rx y,^-�I r r _:• p� -t +.iy,{{ri Jf t t_.r.N-16 w�". ,.IJy'S't„r r c
}, �rY Sa....Orli rrr�• .Jt.;7 rl{f+ 1J.r.Y y :'J Se+Sa 't}�[}{ rr e i 4�tt
Ilk
1:1 lUtYi t y r{ qi ti, .:flt•}'yl t t r^, .r.
,
>I
4 7 C U1.
,y•,py ..1 .k t Y/-^.ta !£ �-..t:t i'`? { t ,.: - ( iL+\' {tJ t`!• a a ` JJ:ft�'2v'YV , Y�y+ u i ndr'rr�
2(( ` 0 „7`t Irhy:e?''i�r f�.l:�{t i T}..• ,.\ >:. \. , '{-�yr'� r/�J�I"F{'}� +d!�t •!'�ryy� `�
F 11• v .Sir f e 6 r+,i�iJT t 4. _'.r _k! 5 Y j�(3.!,,�rlj 4.r y�A 4,� X1`
N rµ311 b
dµt�, ,� i'i qr'+rel ;1 jrr'(.i t ) .!}3 7 k ave , k•S/AJ)l�:ry�� '� �r I� a6 3,.
NJ, N d
,CK `�.B,,,�t• ,r tl .�S X�`�i ray. nit v 3� r>. ' � Y�4j d tJ]! �� �r ?� }-* P j 3
-�'��hriJt�,��,�1�
.,� � �yi�7M 'f{ It! � I 1 T,_ '>.�$•..”! �}F xl1 '�04 , Bio tit of ,r rYJ�l+ +aa+ h.3"!1x+t��tr �.�a�..yr�;:b ,�.
rk
i. `,� � ' Y Il t r t �• 'y ! 5. n.,rl "•'„{} a d •t'h tF hfss''4r• ,>t f,
a• t .3 3 x j' J r ;t ' ' " x.(+ 1#�'t:�F r 3z 1f•1\j S$�F T €:.!
.k' .'r , +S• k t{'{} r rr \ ly !. '� dN,r i^< t,y \Tt. L nit(
i�',,1.,:}'}�d�r' ft�ta�{:: t + r Si iv`.�7^ �`tl ' ':sr'l•'Y�;. M��,r+�. .J,r
PiA
k,kt�J34r Y it-MI1`7r+a3v i j r
l �r ! AI:I tl , a , i �A3.(�•• li{,
y y r tY I r✓~< f r, r ` ( ^tr L >ti
+NF1 fpt„ �r..+ !rdj,�,yI,�r
t. •rt {r ��1.} !i„th17 z�i°i "•• t r .i r• , r 11 cj,i..l'r1•!{k r':7'' .{Yi#'rrrl''.'° y
•rr r 4 s r - r t it '.t+i t 1 t- .,k. F t'a`i• tit g
yy{ ri Y, Yil r i 3 4 4 1j < fid R H � i
1 g
,'
♦ 't 'T t,rl�Pa'1�1�,+�,�I! f,,tt�'P/7)t u`,� .I , \
�� tl i.il'li�\l'�} �¢.3� , tl:,� i �k j , s,r a .. 'i & , I to I�r y�y1G�•:'�,1 1yy++
in t ,i.c r r .r S'1'3 {1 a al}1 ! i t ,'•'i >. r '^ 7 .r ♦:'."i",,"�, Y'
•' tyljy y'• ,`�4 tr\.Y •z,i`\473t, C E �,"i�� \I' 1 :1'4 4,tv d•f+`yM1'7+ f,1',i in
iX)f
w 1' w:k%r, otiS•Y E.�,k;rn ..$".", vi31' r 7 ,5.c„Fr,t Fri i-M>r 4.h♦ k 6„ S K l
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE
Davie County Health Department
Environmental Health Section D
P.O. Box 848 AUG ' 11997
O Mocksville, NC 27028
(704) 634-8760
I
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed Tc6e fit S cP06A k0(,l.6D✓ y Contact Person ST�`'U ROtt. 0A111
54w, x162 51 )
Mailing Address��piG�}1. (-,FA�'Q. l3t.UD , k�u��V� Home Phone
City/State/Zip W I L1510M �t_iyoht.G. �'�lS� Business Phoney 5,66
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [ ite Evaluation [ ]Improvement Permit&ATC [ ]Both
4. System to Serve: [?House [ 1 Mobile Home [ ]Business [ ]Industry [ 1 Other
5. If Residence: #People #Bedrooms 3 #Bathrooms _ [r,J6ishwasher[,garbage Disposal
[-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: [ ] County/City [,i Well [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [/No
If yes,what type?
PROPERTY INFORMATION REQUIRED:***IIVPORTA,NT***AXLAI OF THE PROPERTY MUST BE
,!� Q t lla SUBMITTED WITH T APPLICATION.
Property Dimensions: �2�,�3 ( X aDr' !./S�IG�OI�1 WRITE DIRECTIONS(from VIocksville)TO PROPERTY:
Tax Office PIN: # - �� P"�'-' ���0 �O c� LOITS RD
Property Address: Road Name zo f-4111 AT (5417 Gf Py i 1S 90
city/zip U a n L-f�l
If in Subdivision provide information,as follows:
Section: Lot#:
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 E R to conduct all testing procedures uy
DATE SIGNATURE to determine the site suitability.
� J ) 5 �"l"�(�
Revised DCHD(06-96)
THIS AREA MAy $E USED FOR bRAWINCG JOUIt ITE A-AN:
I I
Z55-2x' S 83°00'58,,E TOTLS
643.85• °�
c� g 16'
w N N
/ 388.67' �0(140
4- /
M, - _ N
s�°r� vg� Nil
SET
z2 24S>--� 4
ze.
A
5.1524
ACRES+-
NCO 1ro��Q \yp \90 00 .
/ xJo 01 �lS
00
POND �Cl)
IRON SEfU
\ +� '\ /
3 � '0 2.9 21 AC ES+-
}e � N�
a
Ofy ?� T .�
3RONSEr 5.3078 ACRES+� ^ \ \�o60 /
ry
C�'
00 � / \ ♦�,� tom• / 4
73 o�f�
4g�S9' (�
IRON SET /
D.B. 1 1 1 PG. 69
S_43026'11"W 79i
/ KfST
S 43026'11"W 37.00'
---------�,.17.7 9'
k
N a., 2.361-V7
205.7 S 35052'28"W
IRON FOUND 2 Ire
N 83° ,
e2 45 'yy a
RICHARD MABE fi+sp`K�S� POTTS F. D
D.B. 148 PG. 217 I JOHN RICHARD HOWARD certify that that -j" {
this map was drawn from an actual �.OP�• .„ 'O ry '
field survey urrder my direction and Q
supervision, that the ratio ofJ t 1'
SEAL
precision is 1P
�yd. �o
RD
REGISTERED LAND SURVEYOR L-2890 u1604161"tw
j `
, " z
:• DAVIE COUNTY HEALTH DEPARTMENT
A�
' Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED 5
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION ROAD NAME
Water Supply: On-Site Well Community Public =-----
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L. L
Sloe%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH r
Texture groupG
Consistence -
Structure F-Y s
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 RATE
SITE CLASSIFICATION: (1 EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: T 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
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
Mineralogy
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)
LIAR-Long-term acceptance rate-gal/day/ft2
DCHD(01-90)
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■ecce■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■�■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■noon■■e■■■■■e■■■■■■■■■■■■■e■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■e■■■■■■■■■■■■■■■■o■■■■■■■■■■■■■■noon■■■e■■■■■■■■■■■■■■■■■e■■■e■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■e■eee■ee■■e■■■■■■■■■■■■■■■■s■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■e■■■■■■■■■■e■■e■■■■e■■■■■■■■■■ ■■■■■■■ee■■■■e■■■■■■■e■■ee■■nee■
■■■■■■■■■■■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■e■■e■■■■■■■■■■■■■■nee■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■on■■■■■■■■■■■■■u■noon■■es■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■noon■■e■■■e■■■■■■■■■■e■■e■■■■e■
■e■■■■■■■■e■■■e■■■■■■■■■■■■■see■■■■■■■■■■■■■■■eee■■■■eeene■■e■■■■■
■■■eee■e■■■■e■■■■e■■■■e■■■■■e■e■ ■■■■■■nee■■■■■■■e■■■■■■■■■■■■■■■
■■■■ee■■e■■■■■■e■■ee■■■e■e■■ecce■►.�■■■■e■■e■■■■e■■e■■■■■■■■■■■noun
■■■u■■■■■■■■■■aeon■■■■■■■■■■■■■■ee■■■■■u■■■■■■■■■■■■■■■■u■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■..�.noon■■■■■■■■■■■■n■■■e■■■■■■■■■■
■o■■■■■■■■oo■■■■■■■■■■■■nae■ears■ ■■■uun■■■■■■■e■■e■■■■■■■■■oo■■u■
■■■■■■■■■e■■■■■■■■■■■■■■■e■■■e■e■e■■■■■e■■■■■■■■■■■■■■■■■■nee■■■■■
MEMNON :iiiii, nomomi MEMEMEi iiiiiMEMNONNNE ON
■■■■e■■■■■■■■■■■■■■■■■■■��■■■■■■■■■■■■■■■■■■■■■nee■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■■one■■■■■■■■■■■■■■e
■■■e■■■■■■u■■■■■■■■■■o■�,■■e■■■■■one■■■■e■■■■■■■e■■■■■■■nee■■■e■ee■
■■■■■■■■■■■■■■■■■■■■■n■��■■■■■■������noon■■■I■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■e�..:■■■■n■s■■■■rye®e■■■■■■■■■■■■■uu■■■■■■■■
■noon■■■■■u■■■■■■■■■■■■o■■e■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■e■■■■e■■■�a■■■■■■■■■■■e■■■■■■■■■■■■■nee■■■■■■
■■■■■■o■■■■■■■■■■o■■■e■■■■■■■cone■■■a■■■e■■■■f,��■■■■■■■■■■■■■■■■■■u■
■■■■o■■■■■■■■■uo■■■■■■■■■■■un■eee■■■■■■■■■■■eee■■■■■■■■■■■■■■■■■■■
■■■■o■■■■■■■■■u■■■■■■■■■■■■■■■■■ ■noon■■■■e■■■■■■■■■■■■■uo■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■o■noon■e■■■■■■■■■■■o■■■■■■■■■■■■■
■■■o■■■■■■■■■■■oo■■■■■■■■■■■■eee■■■■■■■■■■■■■■e■■e■■e■■■■■e■■■■■■■
■■■■■■■■e■■uo■■■■■■■■■■■■■■■■■■■■■■e■■■■■■one■■■■■■■■■■■■■■■■■■■o■
■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ou■noon■■■■■e■■■■■■■■■■■■■■■■■■■■■
■■■■■■■ee■e■■■■■■■■■eee■■■■■■■■■■■■■e■e■e■■■■■■■■■e■■eee■eeee■■■■■
■■■■■■■■■u■■■■■■■■■■■■u■■■■■■■■■■■■■■■■nue■■■■■■■■■■■■■s■■o■■■■■■■
■■■e■■■e■■■■■■e■■eee■■■■■■■■■■■■■■■■■■■■■■e■ee■e■■e■■■■■■■■■■■e■■■
■■■■■■■■■■■■■■■o■■■■■■■e■■■■■■■■�■n■■■■■■■■■■■■■■■■■nue■■■■eee■■■
Davie County Health Department
and -Come Health agency
Environmenta(Heafth Section
P.O.Box 848/210 HOSPrrAL STREET
COURIER#09-4-06
MOCKSVILLE,N.C.27028
PHONE:(704)634-8760
August 8, 1997
Joseph Stephen Holladay
Medical Center Blvd.
Bowman Gray School of Medicine
Winston-Salem, KC 27157
1
Re: Site Evaluation
y _
Potts Road/2.951 Acres
DB-156/Pg. 796
Dear Client:
As requested, a representative from this office visited the
aforementioned site on August 6, 1997;. Based upon the information
provided on the application for site evaluation and after the evaluation
was completed, the site was found to"be provisionally suitable for the
installation of an on-site sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental Health Specialist
RH/wd
Enclosure(s)
Davie County Health Deparhmnt
and Home Health Agency
Environmenta(Health Section
P.O.Box 848/ 210 HOBPffAL STREET
COURIER#09-4-06
MOCKsvaLE,N.C.27028
PHONE:(704)634-8760
October. '8, 1997
Mark Beverly
1163 Crescent .Ct.
Winston—Salem, NC 27127
Re: ` 2 Site Evaluations
Potts Road/2.9521 Acre Tract
Tax PIN: #5880-17-8787 -
Dear Client(s) :
As requested, a representative from this office visited the aforementioned
sites on August 6, 1997, and October 2, 1997. Based upon the information
provided on the application(s) for ' ' ite evaluation(s) and after the evaluations.
i were completed, the sites were found to be provisionally suitable for fhe
installation of an on-site sewage d`i•sposal system on each site.
Before any permit (s) can be issued the appropriate application(s) must be
filled out and the house/mobile home. location(s) staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RH/wd
Enclosure(s)
cc: Zoning Office
y