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1039 Underpass Rd ' �� - � DAVIE COUNTY HEALTH DEPARTMENT � Environmental Health Section �!�'2� �� • P.O.Boa 848/Z10 H�pital Street � Mocksville,NC 27028 (336)751-87G0 Account #: 989900063 Tax PIN/EH#: 5881-40-3824 Billed To: Larry McDaniel Subdivision Info: Reference Name: Location/Address: Underpass Road-27006 Proposed Facility Residence Property Size: 7.884 acres ATC Number: 4222 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MiJST BE ISSUED 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 Treahnent and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION S VALID FOR A PERIOD OF F YEARS. � _.r Environmental Health Specialist's Signature: Date: CERTIFICATE OF COMI�LETION **NOTE** T'he issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article I 1 of G.S.Chapter 130A,Section.1900"Sewage Treatment and Disposal Systems,"but shall in NO Y be taken as a guarantee that the system will function satisfactorily for any given period of time. J��d�-�� 9c�. �=�� , Septic System Installed By: /� � /�� Environmental Health Specialist's Signature: Date: /��'�'�� DCHD OS/99(Revised) ` DAVIE COUNTY HEALTH DEPARTMENT - . � Environmental Health Section - - ' . � P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 , ' (33G)75]-8760 IMPROVEMENT/OPERATION PERMIT Account #: 989900063 �� Tax PIN/EH#: 5881-40-3824 Biiled To: Larry McDani�l ) � Subdivision Info: Reference Name: �,7`C��t �� r�s�n �OZ Location/Address: Underpass Road-27006 Proposed Facility Residence Property Size: 7.884 acres ATC Number: 4222 **NOTE**This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An AUTHOWZATION 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:Y� Washing Machine:� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply� Design Wastewater Flow(GPD)��_S�: New� Repair� �( <i � System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Width�� Rock Depth/o� Linear Ft� Other: J aaCcpted Systems may also�be use Required Site Modifications/Conditions: 11�1PROVEMENT/OPERATION PERMIT LAYOUT- P ED EFFLUENT FILTER. RISER(S) IF G "BELOW FINISHED GRADE. ****NOTICE: Contact a represen ti e fthe 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 1:3 p on the day of installation. Telephone#is(33G)751-87G0.**** I � �� ,� � . Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) SEP-26-2085 10:00 PM LARRY. MCDANYEL.BUILDERS. 336T511724 P. 02 , Feh 0� O6 2Q:D3� davie oounty envhealth 336 751 8788 P• 1 , +,. -_..__ _� •• � � (! � n� � � � Ll � ' A! 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' / sst � S � � � ,�. � M��U / � / WLS / Mt N�� / �tir / y Y(� / b4L .� ..� sa �� M MY � 9LOL /�..� ` � b2[ i,w � h � �� r � V� � i� Sa0 f IvsoLa �a�' � � � � � �� / � g / .m� � � a �a �a` ' o .�.�.�� 9ZE� � � � aoc� � � � ti � ' \ ♦ \ � s�, � �� 0 �w J \ � � ,� - - - - - _ _ �.�� — — _ �� z� � � � � b, L �` � �� 1 +a � ° ,s� � ��e� traY�l ya \N \ �ID �`/ • � \ Q \ . • � , • � , � SEP-26-20H5 10:01 PM LARRY. MCDqNIEL_BUILDERS. 3367511724 P. 04 ,� �_.._ Isyers: - �'w,` -., ,- "� Boundary , ' '° ,�' ': �•� ', -.,. ,',. �"''�;", �'•'�.r �' ,.-- •.,� �ri��iSUS t'{. �, ~ r f�'" �,,�,. ��4 0 !� ti ,�,'�r �'j !I ..r'�+ �,�.,.,,� ''�, Tracts �'�,;,,1'�,`� �,„,,�� '� .� ,p,,... -�<..,�� '�...�..�, Clty \,f�,,r('� ' ,/'` ,�..'"'�,.""..,�'� ,� -"'"'~'"� � �`�-,�, Bound�ries -w . �� r ,f �� ,,.�"' �s ; 1.,• County , `n,�,,�'' .� � ��"' �'s1 �Zontng r r � �`; ,�� %f �,�`; � .��.r'` Mult�symboi: , fi" ;`t � ,,r � . .'�+r •� �� `',; • .',,,° E911 Flre r.. `w�'r ... ! 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CountylD:�800000139 �14 �Nlghwaye • Accounf Number:62028000 � ��d Dafe:1986/03/21 � MuIt1 Symbol ,:�r.;� • PIN:5881403824 • Ssles Price:$23,000.00 US Hfghway • Prnpe�fy Address: NC HiSh�+tey— � Lega/ �:7.844 AC UNDERPASS RD interstat • Owner Name:ROBERTSqN JERRY � �nty Zoning:R-A Aerlal W �Photograpfiy � • Owner/Addt+�ss 1: ROBERTSON � �nsus Code: physicel JERRY W ♦ City Cade: Creaks and � OwnerlAddnsss 2:R09ERTSON • Fire District:ADVANCE uRtvere REBECCA BROWN . Ftood Zone: E911 *a �� • OwnerlAddtvss 3:PO BOX 339 • F/ood Commun/fy:370308 Addresses Fire • City,State Zlp:ADVANCE ,NC 27006 . Flaod Panel:0045 C �Deparbnents " -0000 • Flood Map Dste: 12-17- ❑Schools a • 4end Value:$52,990.00 1993 ��w�ye� • 8uitdtng Ve/ue:$0.00 • Soll: PaD • Out eu!ldinglExtre Features Vatue: e Township:SHADY MAP_�en� $0.00 GROVE SEP-26-2085 10:00 PM LARRY.MCDANIEL, BUILDERS. 3367511724 P. 03 )avie CQunty,NC Property Record Csrd Page 1 of' • •4PBDOODU139 OU1FiIDEAiqAY LN 17B A08EAT oN JEPAY W ... . _ .. _ I.._2QD.5�......._...@.�9A_.�iM . . - - 'N1T5 'ERT�dN�AJEYAFt'Y"C4.'_._.........__....._...._.,._.__._.-ii��E'�'��b�t�RLBECCA"�itC�`N..._�....__...._.......____,...._....___..-F8___ _6 3 ; 00 062aZ8000 LN MaU B M B y 9p1 ti n��-p�� 2D NO: B81 03� 4e DAVIE COUNTY (2005 REVAL) 7 gq AC UNDERPpSS AO 7.47ACRD N0. 0�000 1 SR — qiN „A�,PAAISED....9X...O.T...GN....G]L.R1L,2.AQ5.�.A.7.S.AZ,..MO.CH9....Cli4HC8.,,...,._._.._...........__._._.. . __T9ir_OZ__Cr_.__.__.EX-_._._ATc.__.1,AS.T...ACT.I.O.N.,..2�QSp1Q�..... .,...__.....::lJhI7T111iC�_1l1t�1...nrTA'C2.---._.__.._._ _..;.._ ...r�___..__._......._ il:,l;.....V.AS,t1J;._. 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Box 848/210 Hospital Street " F�t�TM�� --� Mocksville NC 27028 �"' �;� ;4�t�;1�,".w_ , �.,�'r��,f�ItT��H GAV!EG}!�fdiY (336)751-8760 Q:ff�� m! �tur�n:. ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. .�- — IJ'n 1. Namo to be Hilled (., � Contact Peraon _��fi- � Mailing Addresa �1 � Home Phone ��- [(�� /(�, City/State/ZIP �(��jV(C�Q . �(�. �6bj� eusineas Phone �. 2. Nazne on Permit/ATC if Different than Above �/T/7' Mailing Addresa " ' City/State/Zip 3. Application For: �ite Evaluation ❑ Improvemen� Permit/ATC ❑ Both 4. Syetem to service: L�House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. lype syatem raquested: L"I Conventional ❑ conventional modified ❑ innovative 6. If Residence: # Peopla �_ # Bedroomn �� Bathrooms _ �� iahwashar ❑Garbage Disposal � "�hing biachine QH sement/Plumbing �Basement/No Plumbing 7. If Buaineas/Induatry /Othor: verify type ------ ---- --#-People- -�� # Sinks ' " . .. : . , . # Commodes # Showera # Urinals # Water Coolers IF FOODSERVICEs # Seats Estimated Water Usage (qailons per day) s. z�ype of water supplys �'County/City ❑ Well � Community 9. no you anticipata additions or etpa�isions of tlie facility tl�is system is intended to serve? � 1'es Ly'1Yo If ycs,ivhat typc? �� , , ***IMPORTAN7'�**CLIENTS A1UST COA�PLETE TII� RL•QUIRED PROPCRTY INFORMATIJN R�QU�STGD -- BELO�V. Eitl�cr a PLAT or SITE PLAN MUST BE SUBNIITTED by tf�c clicnt �vith TI1IS AI'PLICATION. Property Dimensions: �-} �, 1VI2ITE DIRGCTIONS(fro►n 119ocksvillc)to PROI'GRTY: T�X orr�c rirr: � �5881`f O 3��`� ��d �t' -tb tKJ�1 f3a( . ,�I PropertyAddress: RoadName��,pc-/,Y)�5 � ��'11.�"�� U►1CY!Qb'bC� �� t�C" � c;tyiz;P�,�� 7hd� c3,n (�n�c�p.r-pr�Ss ��w /-�-fl�nd�, T ._.__ , _ _ _ If in a Subdivision rovidc mformat�on a _._ _ - __ ��.. p ' . ,: ; ,-. : ' s follo�vs: __ _ _ .._ ._c'� +V,�.i C ('l�S� �r��t�e rl vl� _ _. . , . . . . . , .. . ,. . - Name: �,/�� .. - . ��K� i,tM 6�Ulp�lrl�'�(�� `Yl IU�P. - � � � c�r Section: Block: Lot: Datc l�omc corncrs Dagged: � � - ��o-OS Tl�is is to ccrtify tliat tlic information providcd is corrcct to thc best of my In�o�vlcdgc. I undcrstlnd tliat any permit(s) issucd I�ercaftcr�re subject to suspension or revocation,if tl�c sitc plans or intended usc cl�angc,or if tl�c information submitted in tl�is appIication is falsificd or changcd. I,also,rurrlcrstau�l thnt I n»r respo�rsiLle jor all clra��cs iucru•red fron� tJris applicatio�i. I,hcreby,givc consent to tIie Authorized Represcntative of tl�e Davic Coimt IIcalth Dcp rtmcnt to entcr upon abovc described property located in Davic County and o�vncd by [u conduct all testing procedures as necessary to deterii�iue the site suitability. � DATE ��- �� a C� SIGNATUIt� THIS AIt�A MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc al!of tl�c follo�vii�b: Existing and proposcd property lines and dimensions, structures, sctbacks, and septic locations). _ Site Revisit Cl�arge _ , _.. Datc(s): �e/� Clicnt NotiCcation Datc: . �� EFIS: - . Sign given �V d • �/� � ��'�' Account No. ��1�� Revised DCHD(OS/03 Invoicc No. � `� . ��t,. �+� 5'.-�S .,,..�.._ ....: ..: ,.��..>�.._........_.�._.:.... .. r........:..... :...u.a.....,.�r..a..:_..�w,.+........:;,....,.,��.,: i..i:.�..=a.....:.::.....:.M...:..;.r..+.u.....i.:,_:�x..�.. wn..:.�:... , ...,�...�:-� .., ....,-.._ �.�...� .. .. ,...v.i ,.......ac..,.a.. ...,�,.-�..wa..._wi. � �• ♦~ � ' '•Y, C. RAY CATCS certity that on r-'EB. i3 , » g'� , I surccycd thc propert�•ti,Yhowti ��n this plat: ' w , ,�ti' �":• `: that the property lines and Incation of a11 structures a�e accurately shown here�on; that no structure �+c�.l��',c�n�;'this proper�y �� ,:� I��. :. . -. eneroaches on anv aclJacent street or property, and that no strucwre on adjacont property encroactt�.�4•�>n the lit�emises. surveyed." � � � S�1�1� � '" n�1 �i - �C� -�.�G.J <}-v MAGNCTIC NORTH ( D.B. I I 1 -069) '" - `' ' ,..�.•.a __�_ �y't,� S 11:`s: ..•f . �.,,a„<Q.•" ,: ', � �iJO��j°�y R�� F � SO/ � . \\ (,O .�C/ f�0�-...^<< ,�� ' R ��T,yc S2�o3\ ,,; o q l�� Rlv 428�20 �� ' s�s�42�-39;w ,.� 'q Y 6� �' � � �v CH. 68.55 , ( • � 29.6' i� �� • , \ ��nt � i d � S44 -53-32"E� c� W , R = � ,06729 "� 2 8.3' - f'I 83.31' j�,�/ � \ N N I ' \,! .• � 222� ?.s� --�_� � / f S 2�p � .:,'1 5� 4.2' � I S 8°42=06"E•'' point 5'2� �, � 8' \ ��., _;,r,� sr y �_� _ J (� •�,�i io.47�/�..j 8' �9 �2��W . ln N'basa (� � p9�int 2O�''2 �.y. 'J�, M � (p /. .�YS 39�-59'-3,7"E - \ ��j; � 101.28 � 33.15' �•point �, � ' �� Q . S45°50-20"E �i� 'O' / �^ 96. 15' n� ' �N � J /, , point �� . \/ /`�S56�-46'-2; C: ' � ' '�, point 73.0� �'��+ � � J � � S 65°-05'-04"E �� ' � � � �� .'�noil in� 6r�'id9e , / //. N 43°4 t-41 C� � � � 91 .61� Pomt 1� � --��,, , �2.�8,/ f-�17�. � N 63°- 46�- 59��E � by .'l��(;p`�, `�� I 7 3 . 00 ��, ;� poinf � �� , 1 � �� ,� . o � , ��, � '� `�� , �, ; o, PARCEL 140 �g N� 3�' �� PARCEL 139.14 ALICE A. HARTMAN � 4 � ANDREW L. MOSSMAN D.B. 2 8- I 5 I S 60°5Q-09�C pO1" . oa D.B. I 32-2 41 � 62 -I 63 126 � � � �� . o, • point .a 0 f N 75°45'-45�C, " 161.00� �' �ron stakes at o�� corners, point � . � ,n uniess noted otherw�se. , 23�9s?�� 3 �' 'sr3;, � . / � TF� / \�R�F� � PROPERTY OF' JCRRY W. I�OBERTSON E REBECCA BROWN I 3 9 DAVIE COUNTY TAX MAP F —8 LOT NO. _ __MAP OF — ___ _.___ _ BLOCK NO. _ SHADY GROVE TOWNSHIP, DC ED Bootc _ �30_ PAGE _4 I 4 ___ OAVI E COUNTY, N. C. SCALE: 1 INCH= 200'FEET JOB NO 1222—A fOVTN[IIM •MOTO ♦IIIMT • •Y►►LV CO.—wIN�TON•�AL[Y N50o9c . � . DAVI� COUNTY HEALTH ll�PA12TiVI�NT ,` ' � Environmental Health Section Soil/Site Evaluation � APPLICANT INFORMATTON PROPERTY INFORMATION Account #: 990003468 Tax PIN/EH#: 5881-40-3824 Billed To: Jerry Robertson Subdivision Info: Reference Name: Location/Address: Underpass Road-27 06 � ,^ Proposed Facility: Residence Property Size: 7 +acres Date Evaluated: � �S Water Supply: On-Site Well -Community Public v Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca osition Slo e% G HORIZON I DEPTH o ` ' '��/ Texture rou '/_ S Consistence Structure Mineralo HORIZON 1I DEPTH �s "' � s Texture rou G'-' Consistence - / Structure � � / Mineralo . / � � HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON N DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS - RESTRICTIVE HORIZON SAPROLITE , CLASSIFICATION 6 u/=..� 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-Tenace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty day loam SIL-Silty loam CL-Clay loam SCL-Sandy day loam SC-Sandy clay SIC-Silry clay C-Clay CONSISTENCE oist 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 tru 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 ote ' 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-tertn acceptance rate-gaUday/ft2 , DCHD OS/99(Revised) ■��■ ■��l�� :::CSC�C�:�:::::C:::::::::::::::�:::C::::::::::::C:C:::::::::::CC ....�............................................................. .... ..■.......................................................... .................................................................. ......�■.......................................................... ...... ........................................................... ...... .........................�..�............................. ...... ......................... .�:�............................. ::::'� :C::::::C::::C::::C::::CC:::::��C:::C:C:C::::C:C::C::C:C:C .._■�■ ..............................�...........................o .. ...�........................................................... ...... ........................................................... ::::�:�=C::CC:::::C:C::::C::C:::�::::::::::::::::C:::C::�:::�:::: ..... . ................................................�......... ..... =C................................................�.......... ..... ........................................................... ... .. ............................�.....................�,........ ...�..�. ......................................................... .... ... ..........................�.....................,......... ....0 .. ....................... .�.............................. .. _.�.. .......................�3......................,.......... ii ��iiiiiiiiii►ii�iiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiiii�i��iiii ■■ ■��►��■��■��■��e��, ��■■ ■�■ ■ ■��■��►��n��n��ri�■ ■��s■ ■��■ ■��►��:c.��■�■�■��■ ■�■ ■ ■��a��s�� ■ ..... 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Box 848/210 Hospital Street ' Courier 09-40-06 Mocksville, NC 27028 � �� -��.�-�-� � � --� �.; �°ti ��h �� , � ""�� (336)75�1 8760� a�� , � r r � �,�: � ��`5 � S ,� � e; �"� ��. r e � rc ''� Y r" s �'_ : e �e . �.;.�` ' �� .§r sa -` � .,, 7+" :� i�. `" i z� . F�� y �a.lyP��. : � ;�� " "b "7-a; r � ; „� s � � `�. � �wh fl-F x�: Q �. a � ' i .. e �; d Y e �. A <n p K '° " < _ -.t� ., =y.. k„ ,e J_ �w '2 , �!1 , � � . . „• -, t ��..' ,,, . , ....F ,� ,,, sm4ueb.a:..,,�a ".".v..�.sa.A��wcrFa£an.w.��.w.�mw:.w.e....x.a..m.acwa..��.,,,aaaMe,,.. �«s........�....u..��w:�.+..w�:�.wu. � February 2, 2005 Jerry Robertson P.O. Box 331 Advance,NC 27006 Re: Site Evaluation/ Underpass Road Tax Office PIN: #5881-40-3824 Dear Client(s): As requested, a representative from this office visited the aforementioned site on, January 25,2005. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site,the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions,please feel free to contact this office. Sincerely, ,��'.�,,��• . Robert B. Hall, Jr.,R:S. , Envirorunental Health Specialist RBH/dlf Enclosure(s)