425 Potts Rd (2)DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990000711
Billed To: Matthew Beverly
Reference Name: Mark Beverly
ATC Number: 4068
Tax PIN/EH #: 5880-18-6088
Subdivision Info:
Location/Address: 425 Potts Road -27028
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: / 1i�j" Date: / `e�Y t
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this 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 s�a guarantee that the system will function satisfactorily for any
given period of time.
��aF s�-Primo.
Sepi
Environmental ealth
e04 o,J .
LOC-
DCHD 05/99 (Revised) I50
SG(.X-
Date: /0
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #:
990000711
Billed To:
Matthew Beverly
Reference Name:
Mark Beverly
Proposed Facility:
Residence
Subdivision Info:
Qd6i,z1Z
Location/Address: 425 Potts Road -27028
Property Size:
nacres /
**NOTES* TTiIs�mprove0meent/Operation 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.
Residential Specification: Building Type #People #Bedrooms Q-:5' #Baths— r'
Dishwasher: Garbage Disposal: ?T� Washing Machine: Er-� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type / #People #People/Shift #SeeaElts Industrial Waste:
1//
Lot Size Type Water Supply L '6 Design Wastewater Flow (GPD) Site: New B—IRepair ❑
System Specifications: Tank Sizelbf OGAL. Pump Tank GAL. Trench Width -34 Rock Depth 1 ( Linear Ft.NTdb
Other: As stated in 15A NCAC 18A.1969TI
aceepted sterns -may -also he us8
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie 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. on the day of installation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature: Date: //2
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
F P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990000711 Tax PIN/EH #: 5880-18-6088
Billed To: Matthew Beverly Subdivision Info:
Reference Name: Mark Beverly
Proposed Facility: Residence
4Pdi11���
Location/Address: 425 Potts Road -27028
Property Size:
4,444;Facres
**NOTES* This Improve0mn t/Operation 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.
2tD
Residential Specification: Building Type #People #Bedrooms Q-:? #Baths�S'
Dishwasher: Garbage Disposal: e Washing Machine: 121"� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type n/ #People #People/Shift #Se173
eaats Industrial Waste:
Lot Size -� Type Water Supply G ,6 Design Wastewater Flow (GPD)to Site: New 0" --Repair ❑
System Specifications: Tank Size/MGAL. Pump Tank GAL. Trench Width��- Rock Depth ZZ Linear Ft.Q &4b
Other: As stated in 15A NCAC 18A.1969(5�
ceepted— Systems -may —also - use
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISERS) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie 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. on the day of installation. Telephone # is (336)751-8760.****
ly
Environmental Health Specialist's Signature: M-" Date: ! l/
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #:
990000711
Billed To:
Matthew Beverly
Reference Name:
Mark Beverly
Proposed Facility:
Residence
Tax PIN/EH #: 5880-18-6088
Subdivision Info:
Location/Address: 425 Potts Road -27028
Property Size: 1.4475 acres
**NOTE * This Improvemeent/Operation 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 ININSTALLING SYSTEM.
Residential Specification: Building TypeZZ #People #Bedrooms v #Bath4��'
Dishwasher: Or"' Garbage Disposal: e Washing Machine: 25"' Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size - eIV71 Type Water Supply 12) Design Wastewater Flow (GPD) 3G b Site: New Repair ❑
System Specifications: Tank Size/( GAL. Pump Tank GAL. Trench Width '36 �' Rock Depth /z4 Linear Ft.30
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie 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. on the day of installation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date: v
f• •
i
APPLICATION FOR SITE EVALUATION/INI PROVE&I ENT PERM
Davie County Health Department
EnvironmentalHeaith Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
0 *'-Rn§fl
�ApR 2 8 ?ODS lU/
e -"%*,
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLE �h""
`r
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for in!
1. Nameto be Billed Al "k 4 g e -y i-�AL.,q L Contact Person /
Mailing Address 116 3 if r e, -s G �1 l C�`� — Home Phone (3 3.b) 7 A q —D t `/ 7
City/State/ZIP U/— sf Al e- -%Pmk Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: �❑/ Site Evaluation 13 Improvement Permit/ATC 8"'B o t h
4. System to Service: L►S House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
S. Type system requested: IJ Conventional ❑ conventional modified ❑ innovative
6. If Residence: # People # Bedrooms # Bathrooms
RDishwasher eGarbage Disposal VYWashing Machine OlBasement/Plumbing ❑Basement/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: 9 County/City ❑ Well ❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? I>(Yes ONO
If yes, what type?
***1A,tP0RTAIVT*** CLIENTS AfUSTCOhIPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN IIfUST BE SUBAfITTED by the client with THIS APPLICATION.
Property Dimensions: "'r v _ )WIzlaj WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # S'V$ 0- 1 W� D 9 ,�I r- /-s--,g �a.s Tv $`0
Property Address: Road Name gas / dffS R d - k -r (/v .�1 D r� � D � y� � 11--s
City/Zip Al L 0.7006 To /0o -11-s o k . ke--Y .f
If in a Subdivision provide information, as follows: o l o T`i Y 04 fa `C r %fid
Name:
Section: Block: Lot:
.mss Qek7-J Q,,11. �;✓�
Date home corners flagged: A o
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 ant responsible for all charges incurred frau
this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcalth Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine.the site suitability.
DATE ����SIGNATURE c•�'� �� `�L
TRIS 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).
C� Gc
0 19 /
Sign givcn� D � "
Revised DCHD (05103 1 {
�- .el
Site Revisit Charge
Datc(s):
Client Notification Date:
EIIS:
Account No. / / o )D D -7/1
Invoice No.
Pro P^47 e�' G n' f-' l vE , tl'/o -To 0-e-
' _7
/ m
IRON FOUND Yo L(_ Cv
3
TOTLA
58"E 643.85' °�`
6 601
.388.61, ,���oGN 1x61
° cv -Z
/l
N)
o °'N LARRY HICKS
�0) ° D.B. 158 PG.
N u-)
O
2 �
4AIRON SET 1997
SANDERS JOB
M 1.4104 ACREScv
o
3.7420 ACRES
0 "RON FOUND JAMES SANDERS
h
DECK
i
1 STORY FRAME HOUSE
co
¢8r ! �'S� IN 4 PoA-s )a—
/ r S�
/ A N V)
C
Pox
p'y I on O < Pr ,f vsel e-
-'�o� N � vi is Z ` F•- o,..� r�.L,.s � �
vo IRON SET
! S ! \"O
! i
ro' .•� 1.4475 ACRES IRON FOUND
r�.
JAMES SANDERS
cr `� Cn D.B. 154 PG. 829
w '`'W�sr1 /' % Tire
1.5046 A S N r. -�'
c0 y
gONS� !��` OWE �4, !�, %o Ke—[C rV�y��, Awh
�;^ �, Pte` /�.5.�° "
o � N
T0 -OIL
O �
,
0
Qo�\ �ss`O• a���
X80 ss,,; �.� � F eA REVISED
,g \`3S'�� REVISED 5-14-04
/ S 4302611 "W 79.03'
/ spiky
/ S 43026"11 "W 37.00'
100 0 . 1
! 205.72' S 35052'28►'W
uND N 8,3012,45" w GRAPHIC :SCALE — FEET
P-OTTS . ROAD'
MAP .
:HARD HOWARD cerEifv that FOR KEITH . L. �C
APPLICANT INFORMATION
Account #: 990000711
Billed To:. Mark Beverly
Reference Name:
Proposed Facility: Residence
Water Supply: On -Site Well
DAVIE COUNTY llEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 5880-18-6088
SuYdivision Info:
Location/Address: 425 Potts Road -27028
Property Size: 1.4475 acres Date Evaluated:
Community
Evaluation By: Auger Boring Pit
Public !/
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
y
HORIZON I DEPTH
a
/'
Texture group
Consistence
Structure
l
Mineralogy/
HORIZON 11 DEPTH
Texture group
Consistence
Structure
Mineralogy-
HORIZON III DEPTH
G
Texture group
Consistence
,
Structure
0-
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
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
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
ois
VFR - Very friable FR - Friable FI - Firth VFI - Very firm EFI - Extremely firth
w
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)
LTAR - Long-term acceptance rate - gal/day/ft2
DCI In 0.5/99 (Revised)
����/�������� ■��/���/�����/�����■ �������� ���� �������� ■ �� ■■
:::::::::::::::::::::::::'::::::�3'C:::CC::B:::C:C:::::::.' �: �'�
.■..C■■■■..■■■■.■■■■...■■■■...�.....■■■�■...■..■■.■..■■■...■■.. ■ S
.... ..................................................... �C
.■■........................................■.........
........................................... .. ..... .. ..
�����������������������������������������r� C��C ���������� �C
..�■■■■■■■■■■■■■ ■■■■■ ■■■■■ ■■■■■■■■■■■■■■■■■�■■■■ ■■■■■■■■u
■■ ■■■■■■■■■■■■■■■■�■■■■■■■■■■■ , ■■■■■■■■■■■■■■�■■■■ ■ ■
............................��'...................=C.CC� �
................................................. ...... ..� .
■s������������ �����������������������e����������������� ■
..............C.........................................�D=.
......�......................�.....�.......................
...... ...................... ..... ............. .......
........ ........................................ ....... . .
........�....................... ..... .... ....8.......EE C .
........ .......................�.....C.... ........■..■.■ ■ .
■���������������������������►;������������������������������ ■ ■■
■������������������������■�������������������������������� ■ ���
.■.�■■������■��������������������r���������������� ����������
■........�...■........►.................��.........��� � �:
...�r�� ���������� ������������������������������ ����������o�■ ���
..� .......................,...............�.. .......... . � . .
..�........�..........►..,...�.....�..�..��.......■.�.�6 6 Q
ii�iiC�iiiiiii�'iiiiiiiiiiiiiiiiii��iiiii�iiii i iiiiiiiii�i��i
�......�......�..........►.................�.�.�...........■■■ Q
...... .■....�..................■■.......■�■■■ ■■■■......■ L�
�:::::E:::::::�:::::::::�:::::::::::::::::�:�:E:::::::::: �: '
iCii�..... ........►�.......�•�.................�............... ■ ' ■�
. ......................�....... ........�............... �. �C ■
��iiisiiiii�iiiiii�ir•'������ �i��������������a���������
. �..��.........�......:::'�::'::�C:::::::::�C::::::'.......: : '
. .. ......�.��.......r.�.��............ ...... . � p
..��. ..C..C......r,��..........�►�............::��::':::::::::��: .
■�� ����������,w������������,r:��s��►��������1���1 ��
.�■.����r�T�y��i����������i�����������������iii� ������������ ■ �C
■ ��rP •c����►� �� ��� t��� �i����������
�.�.�......,�3..�...�,...:CCCtl::::::���::� ::�::::::� � .
■ ��������i����� ��������s���������s��i����i���w������
■r����������►�:::�::!�...�_------������i���� ���t�n;���� ��
■■ ��������__.�----,��i�i��'iiiiii�������o�r�r.,r,
i■ iiii�iiiiiii►ii��� t��������������!��c'�������riiiii��� ■
..� .............:::�:::::::C:::::.�...�.��..........:::5�
��� ���������a'����������'e�����N�iiiiiiiiii�i�i'iiiiiii��
C:::. C��:CC::::.:::::::::CCCCD::::�::::::�C:.: ■ ......... :.
�����■�■ ■ //����t/��������/�/�//1C�����/����11����%���������� � ��
��.■�����%t����/����/����U/�/��������11�����������
... .. ..........::::::::::::::::::::::::;;::::::::::::a: '
...s.. .......,�........................,,.. . 8
.�.....■ � ��.....■�............... ........��..::::::::::: C'
_..... ...........■...�.... ...��.... ...... � C�
i �� � ���iiiaiii���sC ���0��������� ������� ���� ■ �
i� ■���t����iii��iii�Ci�Ciii�i�iir�t���i������ S�� �
.�. � .. ..�....... ......�....... .,,... ... � .a . a
��'���r ��C�� '���i������� ����i���'�C���'�� C� �
���� ■ ��� �� �t��t������ii'iii������������i��������� ��■ ■ �
���■ ■ �������i .►r����������C���i""isiiiii��i���� ■■ �'�� ■ �
C .� .... .a ........... .��.... ..C...�. �
....�.....��.. ..........:a::�.........� ...E........ o
����������������Q ���������������iiii�����i���� ������r� �e
::::�.... ............C...................::::�::::�:CC:::'::�C
::CC::C::::C::::::::C:'..�....................■.�.■
....C..■...................:::::::::::::::::::::::::::::?� .
�..C�... .......................... ........... .. ........ ■
C..........................�........... ..�■...... ■
... .......................................�..........�a ..
......................................................... �.
...�. .........o... ............................. ...... ...�
. . ...........�............................. ...... .
�■■.......................................... �.... . . �
■■.■..... .■................�.�........�■...._ .
............. ...............�. .................�
:::::.............. C:::::::::C::: 'C:�::::C::: p ...�. �
::::::::::...............9�a�...........�.6::�.: :
�. m
`06
8
2J.
115311 W SRO
0 3 N s"
p �ROly S"
�z
1.0219 ACRES
ON S
;g „EET
� LOT 3 '
�1
IRON SEi 2004
JEFFERY A. WILSON
JESSICA R. WILSON
D.B.598 PG. 665
N 16°44 23"E 396.21'
(:I
2.2753 ACRES
� � - - i [� yL �! . •`, i'-iLt. i� �. w� _. �f � ii 7 �� y�F . - 4� LI`�tt t��i �J S>
IRON SET 1997
d �- ;7
50 5 53` W
'��. i 1-A Jc10 S Q�j�•i
r
105.56 IRON FOUND
`\\
� "lull 1
Q
Date
IRON FOUND
Review Off
RICHARD S. HARTMAI
D.B. 167 PG. 889
24� 'g2
S o5°2�W
LARRY HICKS
D.B. 158 PG. 716 F
� P�• X53
1�2
'n p0•
V `
IR