218 Vanzant Rd . _,
� -.�r
DAVIE COUNTY HEALTH DEPARTMENT
', Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(33G)751-8760
Account #: 990003755 Tax PIN/EH#: 5719-02-7493
Billed To: Raymond Robinson Subdivision Info: ���a��/V��
Reference Name: Greg Parrish Location/Address: 218�Vanzant Road-27028
Proposed Facility Residence Property Size: 1.729 acres
ATC Number: 4212
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). 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 CONSTR CTION S VALID FOR A PERIOD OF FI YE .
Environmental Health Specialist's Signature: Date: _ �
CERTIIT TE OF COMPLETION
**NOTE** T'he issuance of this Certificate of Comple ' shall in i e the system described on ImprovemendOperation Permit
has been installed in compliance with icle 11 .S.Cha er 130A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY en as a a ntee that the system will function satisfactorily for any
given period of time. �
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Septic System Installed By: ! �1 � �� (�'
Environmental Health Specialist's Signature: Date: 6s
DCHD OS/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
t � Environmental Health Section
d , ; w r P.O.Boz 848/210 Hospital Street �, �
, Mceksville,NC 27028 `'� 3I�
(336)751-87C►0 I�I
IMPROVEMENT/OPERATION PERMIT
Account #: 990003755 Tax PIN/EH#: 5719-02-7493
Billed To: Raymond Robinson Subdivision (nfo:
Reference Name: Greg Parrish Location/Address: 2180 Vanzant Road-27028
Proposed Facility Residence Property Size: 1.729 acres
ATC Number: 4212
**NOTE**This Improvement/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 � #Baths�
Dishwasher:� Garbage Disposal:� Washing Machine:� Basement w/Plumbing:� BasementJNo Plumbing: �
Commercial Spe�ification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �/ Type Water Supply 1��� Design Wastewater Flow(GPD)—�t��`� Site: New❑ Repair❑
'` �
System Specifications: Tank Siz%GAL. Pump Tank GAL. Trench Width S�(�Rock Depth� Linear Ft.�
Other:
s stated in 15A NCAC 18A.1969(5)
Required Site Modifications/Conditions: aCCepted Systems may als0 b8 us�3d
IlF1PROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFE'LUENT FILTER. RISER(S) IF G"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe 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 1:30 p.m.on the day of installation. Telephone#is(33C►)751-87G0.****
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Environmental Health Specialist's Signature: Date: ��
DCHD OS/99(Revised)
����_
.� � � �
_ 's '`� �jLl FOR SITC EVALUATION/IhiPtiUVEAtENT PC[ihflT&ATC
� S�P Z O Davie County Health Department ���
. �
En vironmenta/Hea/t/�Section ��
�F����Zt1 P'O Box 848/210 Hospital Street
,�Ro����a�;�1 Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
�Namo to be Billed .+�onL ,� `.,�ontact Peraon �
�-?tailing Addresa .Zcy�,�.�Z},,� ,PraO xo�e Phone 33(�-�QL-S$/.�
Ci�.y/State/ziP YV��,�v,��e ,�C� 2.7oLFf �—Busineas Phona 3.�fo`�{77-5/o3�f
�. Naate on Permit/ATC if Different than Above�/Z.F9 7AI`ffSJ'l' 1 J�4Y �� ' `-"��•^�5��
Mailing Addresa City/State/Zip
`'�3. Application For: lr�'Site Evaluation Ud Improvement Permit/ATC �
�� Syatem to service: [a'House ❑ Mobile Homo ❑ IIusiness ❑ Induatry ❑ Other
�--5: Type aystem requeated: ❑ Conventional ❑ conventional modified ❑ innovative pacCe ted
/
� If itesidence: t� People _�_ # I3edrooms -3 #� Bathrooms L
��LNDishwasher I.}SGarbage Disposal L�7Washing Machino l,�Basement/Plumbing ❑Flaaement/No Plumbing
7. If Businesa/Industsy /Other: verify type # PeoplQ # Sinka
# CommoQes # Showera # Urinala � wator Coolera
IF FOODSERVICE: # Seata Es�imated Water Usage (gaiions per day)
Vs. Type of watar aupply: ❑ County/City CK Well 0 Community
�� no you anticipate additions or cxpansions of thc facility tl�is systcm is intcudcd to scrvc? ❑ Ycs [H'No
If ycs,�ti�liat typc?
***IA1P� IYTS MUST COdfPLETL•TlIC RL•QUIItED PROPCRTY INI�ORMATION R[:QULST['sD
BELO�'V. hcr a PLAT or SI'!�'C PLAN 1LfUST BL SUQdfITTLD by thc clicnt with TIiIS APPLICA'TION.
Property Dinicnsions: �• � vZ��'^^� WI21T�DIRECTIONS(froni Mocltsvillc)to PROPI'sRTY:`
��a orr,c�i'IN: t�S7/9nz7y93 � � �i<<s h � c� y c.-� �"'
Property Address: Road Name.?Jg Vq�r2.4,�t�- ��t� ,�1 — `�D p�s 5 !/o �. F- � • ""'`
City/Zip Moc.K.s►%,llE�d1 C L7aZ8` �-R-��- ( S�- j-- �/� �° 1�"'��`�
� - -' h,�� �.
I[in a Subdivision providc information,as follotiys: N�A
Namc: {'�''�-'-S� ��
Section: Blocic: Lot: "�ate home corners llagged: g L a.s
Tl�is is to ccrtify tliat tlic information providcd is correct to tlie bcst of my knowledge. I understand tLat auy permit(s)
issued hercafter are subject to suspension or revocation,if the site plans or intended use cliange,or if the information
submitted in tliis applicatioii is falsificd or ct�anged. 1,also,turderstand tltat I nnt respousiGle for n!!clrarges incurrerl fro��i
tlris applicaliou. I,I�creUy,give consent to tl�c Autl�orized Representative of the Davic County IIcaltli llcpartmeut
to enter upon abovc dcscribcd property locatcd in Davie County and owne by
to conduct al tcsli g proccQures as neccssnry to dctcrminc tl�c si ' ity.�
DAT� ZD 0.� �-�3'�NAT � �
TFiIS AR�A MAY B�US�D rOR DRAWING YOUR SI' LAN i udc all of tl�c follotiving: �xisting and proposcd
property lines and dimensions, structures, setbacks, septi cation ).
Sitc Rcvisit Cliargc
� � �. . Datc(s):
6� f��
� Clicut NotiCcatiou Datc:
� �I-IS:
�} a ' �. 7-ss
Sign givcn 1 " '-� '. Account No.
� �� �7
Rcvised DCIiD(05/03 Lrvoicc No.
NOTE
This property is subject to aN sosertme+b. right-of-ways.
drawls and aftsearvients.N any, as the some may appear of lFred Lanier Rd
rocad in the office of the Register of Deeds. Clertu of Court, SR 1307
Taft or Call*Tax Office or which may have been acquired by
- _ prlwelpEk*use. This survey is subject to any facts that may
be disclosed by o full and accurate title search, NOT furnished us
us
as of this date.
�YY 84 ( &►
This map or drawing and any occornpanying
' docunw te acs furnished to the persoMe) nomad
thereon OW no aNerations or use by others
is permitted union authorised by Stone Land Surveying Co. SRe •
Certified copies of this survey mop will not be issued
beyond ninety(90) days of the original survey date.
Mop not for recordation.
aF Precision 1:10,000+
tpQ
4 QW98 rbbOrt Stan.,vrafwiana land swvf'or,L-3162.«racy to on. 41 Vicinity Map (Not to Scale)
of the foNewkq se h+dkeled"fuss ® or
❑ a. That axle►le►Is of a 0xvey°ret create.a.6*Ad.of and ekhin \ 1�
are Oreo of a oeun*or m%adoilpe tr that has an ordnance that-9 porcols
of Ianx Tax Lot 46.04
❑ b That thr peat is of a o.vW Mat le locate.N even paraan of a Tax Map H-2 /
aornty or mrrrfolpaety tad r unregulated ae to an ordk acme
that re9umt-pO1Cete of krr n/f Neil D. Larsson /
and wife /
- 0 c. That"tract Is of a survey of an exisarq parcel or poral. - Frances W. Larsson
RB'605 O PG 247 Tax Lot 45
d. That this PW h of a Survey of another
Elreoorr""tbau
n of existing pomew a art ordered whr"eyy oas r �
r other Tax Mop H-2 / �
�epaarr to tt1e defedd n of subdwMan, n/f Angela Graham Robinso-1
do Regina L Graham /
❑ s 'tet the"rfon"dim evessble to MIs ourveycr in such that I am DB 185 O PG 255
arable to maim a Asksrminodw to the beet of my prateesia al
.blit on b plowbi rr oarrtdrrd in(a)through(d)above.
George R. Stone
Prato"
land Surveyor. L-3162 . \ �`R /
\ f10/ \
\ •;- Vanzant Road
S.R . 115 2
60' Public R/W 20'+/— Pavement
\ �c
g0a / CALL TABLE
°G Tax Lot 45.01 Q�°�oJye
Tax Map H-2 . / COURSE BEARING DISTANCE
X- / L-1 S 39043'50"W 129.00'
1.739 Acres +i-- / L-2 S 45943'50"W 132.00'
_ Per RB 612 ® PG 136 / L-3 S 55°43'49"W 172.33'
I L-4 N 04°14'47"W 40.14'
Tax Lot 46.06 / / L-5 N 04°14'47"W 197.88'
Tax Mop H-2 / L-6 N 37'19'36"E 247.78'
n/f Gerald E. Huffman / L-7 S 51458'58"E 237.07'
and wife 111 / / T-8 S 35443'49"W 147.99' Tie Line
Carol F. Huffman / / T-9 S 39443'50"W 135.00' Tie Line
RB 607 O PG 661Tax Lot I /
r I /
Tax Ma 4H-2 Solid Line: Surveyed Line
I ' / p
/ / n/f L. Roger Powell
Rand wife Broken Line: Deed Line
/ Sue Forrest Powell
DB 95 O PG 564
I
C,019
R/W - Right-of-Way LEGEND FC - Face of Curt,
EIP - Existing kon Pips BoC - Back of C^i-o /t I // / Site Plan for.
E1R - Existing 1-prn Rebar PP _ Power Pole ,
P - Poet LP _light Pole i� Q �/ ' Greg Pa •s
CM - Concrete Monument Mt, - Mar Hole �i / �� / g �}7m h
IRS - Iron Rebar Set CH - Chord Distance % /' f t V
P/L - Property Lire o/C - Part of
C/A - controlled acc.a: ca - Deed Book . Robinson Residence
CP - Concrete Pips PH - Plat gook / 00'CMP - CruMetol Pipe R8 - Record Hook / Tax Lot 45.01
CPP_Corrugated a!ed Plastic Pipe PG - page
-F- 100 Year Flood Boundary CB - Catch Basi'
-o- overhead txaitiss -s- sewer uTax Map H-2rs Record Book 612 ® Page 136
-X- Fang WM - Water Meter �iV`
Fnd - Found WB - Water Vaive !
n/f - Now or Formerly she - Bench Mo'k goes eP+s 1.739 Acres +/-
NMP - Nonmonumsnted Point TBW - Temporary Be,& Me-k '041% per RB 612 ® PG 136
!! opo
CL - Center Line CRS - Rail Rood Spike ��Car COUNTY STATE DATE
EP - Edge of Pavement CTB - Cable , T,Q,qfo Pedest,. ��•yN4set'°f.ted, op SCALE TOWNSHIP
TP - Telephone Pedestal i:?9 - Electn<: �•a-�etormer Bo. ee• �`
-W- Water Line CO - Sanitory Sewer sea• ouI decIathaTc• '✓9 20 1, = 50' Calahain Davie North Carolina 8-24-2005
we su yed: a Pro ty gflown Zn
50 0 _ 50 100 150 this ply f �r; SURVEYED- Stone Land Surveying Company jog No.
SC,DB George Robert Stfine, Ply L-3182 12605
r MAPPED: r ri r;r. r, e `sone 3.36" 998-4733 MAP NO.
GRAPHIC SCALE — FEET —+ cis M r 1 12605
'"041 silts""
, ; .,.. = ..
� DAVIE COUNTY HEALTH DEPARTMENT '
, Environmental Health Section
Soil/Site Evaluation �
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003755 Tax PIN/EH#: 5719-02-7493
Billed To: Raymond Robinson Subdivision Info:
Reference Name: Location/Address: 2180 Vanzant Road-27 28 .✓
Proposed Facility: Residence Property Size: 1.729 acres Date Evaluated: �
Water Supply: On-Site Well Community Public -
Evaluation By: Auger Boring ,�_ Pit Cut
FACfORS 1 2 3 4 5 6 7
Landsca e sition .f�
Slo e % �`
HORIZON I DEPTH 1. ��
Texture grou L G,[.,
Consistence � 1/C:
Structure �- l'
Mineralo /,-(
HORIZON II DEFTH " tJ�-
Texture rou
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 . > S
SITE CLASSIFICATION: � EVALUATION BY: � %
LONG-TERM ACCEPTANCE RATE: ��� OTHER(S)PRESENT:
REMARKS:
LEGEND
i.�ndscaAe 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
�
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
CnNSIST .NC .
�Z41S�
VFR-Very friable FR-Friable FI-Firm VFI-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
SYT11�LuL@
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineraloev
1:1,2:1,Mixed
LY�s
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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Environmental Health Section
P. 0. Box 848/210 Hospital Street
Courier 09-40-06
' Mocksville, NC 27028
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September 23, 2005 9
Raymond Robinson
204 Vanzant Road �
Mocksville,NC 27028
Re: Site Evaluation/ Vanzant Road
Tax Office PIN: #5719-02-7493
Dear Client(s): '
As requested, a representative from our office visited the aforementioned site on
September 22,2005. Based on the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, it was found to be
provisionally suitable for the installation of an on-site sewage system.
Before and Improvement/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.
Environmental Health Specialist
RBH/dlf