1526 Yadkin Valley Rd __ _ _ _ __ _ __ _ _
�
. ,
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
� P. O. Box 848/210 Hospital Street
Mocksville,NC 27028
� (33(,)7�1-R76f1 j
Account #: 990003635 Tax PIN/EH #: 5863-23-4526
Billed To: Lawrence Davis Subdivision Info:
Reference Name: Location/Address: 1526 Yadkin Valley Road-27006 II
Proposed Facility Residence Property Size: 2.23 acres
ATC Number: 2548 A 't�j'" "'
���:epted Systern$ e7��ay ais�� �
� AUIHORIIA'TION FOIZ WASTi�W���I�I�.IZ �YS1'E�I��� (�ONS�I�IZUC'I�ION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED 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 far building permit(s)(in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Tr tment and Disposal Systems). THIS
' AUTHORIZATION FOR WASTEWATER C ST � IS ALID PERIOD OF FIVE YEARS. �
Environmental Health Specialist's Signature: Date: i 2 �'S I
l
CER�TI�IC��TF (_)F <�01�1I'I F��CI(�. �
' *'`1'O"I F.*� The issuance ofthis Certificate ofCompletion shall indicate the system described on Improvement/Operation Permit '
has been installed in comp(iance with Article 1 1 of G.S. Chapter 130A, Section .1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a guarant that the system will function satisfactorily for any
given period of time. � ,�1
�� A �������3
�-�
� �
���� ����''�
�s� - �� �' i,
-- ,�� -,,S �'
�. _ - �
� 7- ��,,,� -',,
� � � 'I
�
4 �,�
I�ak �����
���� ����� ��I
Septic System Installed By: 1��� ,
Environmental Health Specialist's Signature: Date: 7 �
�
DCHD OS/99(Revised) ,
DAVIE COUNTY HEALTH DEPARTMENT ����c��
. . �
•' ' Environmental Health Section
P.O. Box 848/210 Hospital Street I
Mceksville,NC 27028
, (336)751-8760
IMl'ROVEMi��N"I�OPT�,R.-�TION Pl�:��'������i1' �'�
Account #: 990003635 Tax PIN/EH #: 5863-23-4526
Billed To: Lawrence Davis Subdivision Info:
Reference Name: Location/Address: 1526 Yadkin Valley Road-27006
� Proposed Facility Residence Property Size: 2.23 acres
ATC Number: 2548 A �
\(� Y l�:`� 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 I 1 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. ,
1 I
Residential Specitication: Building Type r .��= - #People 2 #Bedrooms� #Baths s„�_ !
Dishwasher: � Garbage Disposal: ❑ Washing Machine: � Basement w/Plumbing: � Basement/No Plumbing: ❑ II
Commercial Specification: Facility Type #People #People/Shift #Seats [ndustrial Waste: ❑ II
' �
' Lot Size ��•2'3�-��=�Type Water Supply�,€'Ll�l�� Design Wastewater Flow(GPD) �: Site: New�? Repair � ��
r
System Specifications: Tank Size C��GAL. Pump Tank GAL. Trench Width�J Rock Depth �Z� Linear Ft.0 C�� !,
Other: LF � As stated in 1!. �FsH.i5e9i�=, I
�7 ��5��1���1��.: ��'Xa:� accented Systc; �Iso be use�
Required Site Modifications/Conditions: �"�TA�L �,! ��1q;�(Z , � ��J��� �S��y.�'�i� A3r`,y� <������
IR9PROVN:MEN�1�/OPI�:RATION PEKMI"T LnYOli"� - APPROVF.D f?FFLUF,NT Fl1,TER. RISER(S) 1F G " BELOW �
I�INISHEU GRAUE. `°`*`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(33O751-876U.*Y*� ,
� '�`r�.�.X 1 v-.�"L+', r�L.���'� II
3�,;�
�� ��:�:i� i.-��;�S i� c:�r�2
�
11�i'� ��� t f t5 ��ts�� �i..T2 w�i
5 �� P��.-
., - � � "�c"' S �� � '' �t���-�c_��:-5
, ,�, a�,,.'
•. � �`1, 7� �� �., `��,�
� C �� � �I
, -
f _
__ p� fSQ �: i
Environmental Health Specialist's Signature: ���� Da • ►2� �j )�5 �Qi:✓ �>I
�.a gs,�r �
� �
,
DCHD OS/99 (Revised) � ��
F�o�'�' A?P�- I
4�0' I
— --— — _ _ — — -- --- — �. � --- --- — _ — -- __ -�
.,...:_.r -:- ,......,��. �.....�.�+.c. -�....-�,�•.,...,Ji-.,;,_..�.,,,,_. __ .�.r�^...,;.r. . . .:�r-.-.=,•- _r.. ... � . _ ' .. . ,
. . -.�. .-...-:�.-�:...,. .... .,.n..:..�,..y�,..�a-�.:..,..
..-ti. ..- ..�. . . . . _......._, -,.
. •. � . . . ^"Y:,.,:.�"�."Z.�'W^�J"_'.�'� .'�'�-.-'ti-.-r^�'�.M_.v �
,. �aPerfiiit�ee' �� � �'� �,� ���]�� �����'� �$�A�.�'� ���[�����'��.
" I�ar-ae:' � •-���-���""`,��st=�?,��.� Environmental I-Iealth Section � , PROPERTY INFORMATION
. � � .
� . �`,��. � P.O. Box 848..
Directi5ns to property: � Mocksville; NC 27028 Subdivision Name:
' ����� ������� � �� ����r�� Phone#: 336-751-8760 .
. j%`` � � • - Section: , Lot;
� AUTHORIZATION_FOR �
�'A�1 ��� '��-�. �yj�'•� �� �'ASTEWATER : - -
. SYSTEM CONSTRUCTION Tax Office PIN:# .
AUTHORIZATION NO: � � `' . . ���Y��'e� ���
����� A � Road Name �ip��"��`��"i�'f,.�"
� **NOTE**This Authonzation for Wastewater System Construction MUST BE I.SSUED by the Davie County:.Environmental Health Section pnor
ro issuance of any Building Pern►its.Tliis Form/Authorization Number should be presented�to the Davie County Building Inspections
Office when applyin�,•fo�Building Pennits.
(ln compliance�t �`Ar„ticle.,�] �G.S�--C�rapt�r�,130A,V1Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
,.'.-,.,.,._ )
!� ,� ***NOTICE***THIS AUTHORI7.ATION�FOR WASTEWATER CONSTRUCTION
� � L ��t�"������/t ' IS VALID FOR A PERIOD OF FIVE YEARS.
�E�NV'IRO M.ENT.�,:�'f4�t'-�SPECIA.I�,T DATL I 5� . .
.. , , � �`; �
,. RESIDENTIAL SPECIFICATION:BUILDING TYPE�_�l.�'#BEllROOMS�#BATHS�#OCCUPANTS �GARBAGE DISPOSA�:'Yes r No
COMMERCIAL SPECIF[CATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZFt�-o��d��WATER SUPPLY��DESIGN WASTEWATER FL;OW(GPD)�Y �i�f,{ NEW SITE REPAIR SITE �T
r ,P
SYSTEI4t SPECIFICATIONS: TANK SIZE�GAL. PUMP TANK GAL TRENCH WIDTH�' ROCK DEPTH ��' LINEAR Ff. ����a
�
OTHER � �6 T���( .0�jAca� M1�� ,. �f"� �{"C��'J�c��'��� � �'��������'��
REQUIRED SITE MODIFICATIONS/CONDITIONS: ����.. K� �y�� ��711 0���� ��e. �-+5�' �� �� a�'��'� '��'�'-'-
IMPROVEMENT PERMIT LAYOUT � � • ••
�� %q �
. . � - � . � ��'" :� � �
� ��� ,,.
,.:. �
ti�' , e�.. , � .
� t �
. ' � .
. . . �� ; �� ��� . .
�- .,����
. � ���, ��. . ,
. � �� �..��' 1�Q� . .
�� ��v-+� �.
� . . ���- � ���'tC.�i��-•. . '
� ������� .
����� �.���..
^, � .t�' c�ca� .
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR L00- 1:30 P.M.ON THE DAY OF INSTALLAT[ON.TELEPHONF#IS (336)751-8760.
OPERATION PERMIT . • . � , ,
' SYSTEM INSTACLED BY:
b ,
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE I$SUANCE 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 02/02(Revised) ' ' � � � . .. . . . . .
. ., , .� ' . . .. .,. . ' ' . �:i� +. , j: .
� f .,
_/ . � '� , . � � ' _ �.
����� ��y
� � � � � � � � � G � dC�
� - APPLICATION FOR SITE EVALUATION/IM1iPROVEM1ICNT PCRh1IT&ATC
� Davie County Health Department MAY 3 1 2005
Environmenta/Hea/th Section �
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 ENUIRONME(�TALHEAITH
(336)751-8760 C�^r�!«nuPdlY _
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNI,ESS ALL TFiL REQUIRED
INFOF2MATION IS PROVIDED. Refer to �ho INFORMATION BULLETI27 for inatructiona.
� . r
; ; G�:v� •� .�_;•
i l. Namo to be IIilled /{i.✓KC.-/!/�.'�: � L�'";� Contact Peroon �'` __
Mailing Addro3n j.�G �OQr?,'�•'��,�,/..��j!F' ��' Fiome Phone �/(�'r J `� '� � r
City/State/ZIP ��! � • i:�� �� 1 ���� � $uaittl�(�s Phono ��-=� ' � � •
TI •�, -1 ,
i ,
2. Namo on Pormit/ATC if Diffaront than Above `
i Mailing Addresa ity/State/Zip
3. Application For: �Site Evaluation , �'Improvement Permit/ATC ❑ Botli
�
4. syatem to service: ,� Houae � biobile Home � Businesa ❑ Industry ❑ Ot2ier
I5. Typa syatem requested: � Conventional ❑ conventional modified ❑ innovativa -
6. If Rasidence: H People ,-� # IIedrooms � tt DathroomD
� . �. � ��. (�rL._�c� 1'� `-,`1�_y��r��. -.�` :�o�.��.�
�Dinhwasher �Qarbago Diaposal �Waahing Machine �Ba3ement/Plumbing ❑Daoemont/2Jo P1wnUing
%' `, '
' 7. If Duninuaa/Industry /Othor: verify type N Pooplc �1 Sinkn �
� # Cou�odea # Showers # Urinala fk Water Coolera
IF FOODSERVICE: # Seata Estimated Wator Usage (qallona por day) I'
s. Typo ot watar supply: �7 County/City ❑ Well ❑ Community ��
9. no You anticipate additiona or cxpansions of thc facilit}�tliis s}'SfCI111S 1llfC11(�C(I �0 SCCVCT ❑ YCS Cl No
If}�cs,ivliat typc?
�***L1iPGRT�iN7"°** CLI[:NTS i1lUSTCOAl1'LGTL• 1'fIL IiGQUIItGD PROPLRTY INI�OIii1�IA'I'ION RI:QUL:S'I'EU
I3LL01V. I:itlicr a PLAT or SITI;PLAN d1UST 111:SUIlb1/7"17:U by thc dicnt witl�TIIIS APPLICAT(ON.
1'roperty Di�ucusions: ' �� k G��,�C.Z�L X�-� ;X %, '� - ' 1VRITIs D(KLCTIONS(from il7ocicsvilic)to 1'ROPI'slt'I'1':
� T�a orr,��r�rr: i� -�r�! ��? 3�.5�. 6 _� � � � ,� � ; , �� � ��I
/G 1 I
Property Address: Road Namc. �fldl�ii�/ ,�/.1//E�//Q�. ,r�.^!t � ;� �D .:�ti" :
r
City/Zip�', r` .�,��.���,� . ���, :� , � ��' � � . � �
If in a Subclivision providc inCorn�ation,as follo�vs: ' '�
Namc:
Scction: Blocic: Lot: Datc I�omc corncrs t]abecd: 5 — .��- !� .��
Tliis is to ccrlify tl�at ilic inCorniation provided is corrcct to tLc bcst of m��kno�rlcd�;c. I undcrstand tliat any per�uit(s)
issucd licrcaftcr are subject to suspcusion or rcvocation,if Uic sitc plans or intcudcd usc cl�angc, 01'II II1C 111COCIllalion
submitted in tl�is application is falsilied or changed. 1, nlso, u�rrlersta�rrllJrat I rrm res7�o�rsiLle for rrll charges irtcm•rec!fi•nnr '
dris applicnlioit. I,l�creby,givc consent to tl�c Authorized Rcprescntalivc of thc Davic Coui�ly IIcatUi Depart�nc>>t
to cntcr upon abo��c dcscribecl properl}�loca(cd in Da��ic Coun(ti�ancl otiF�ncd by /� ';,•. _ " �
I
to concluct :III �CStllls P1'Ol'C(ILII'CS:1S IICCCSSIII')�to dctcrniinc il�c sitc suitability. '
. '�
. � ��
DAT'L� �� SIGNATUR� ��{ ;_ c� -'Z< � �� ,
J
TIIIS ARLA MAY B�USI:D I�OR DRAWING YOUR SIT�I'LAN(Iucludc all of tlic follotivinb: Lxistiug a»d proposccl
propertj�liucs and dimcnsions, structures, sctbacics, and scptic locations).
Silc]Zcvisit Cl�ar�;c
; llatc(s): I
Clicnt NotiGcatiuu DAtc: �
�IIS: .
� / � �- i
Sign givcn Account No. �`'
Rcviscd DCIIll (OS/03 Iuvoicc No. � o � `
. I
�
r . _ _ _
• ` pv/
� � fi
' • ��3TL� �aIa£x��;�rer ���
pU r.� Norih Carofina � �,
Click on the Map to: Map Layers
Zoomin ZoomOut Recenter Map Identify: Parcels :,_, Draw Layers i
Draw selected layers`
Zoom Factor. 5X W;�;j Radius Search(feet)� Boundary i
C Census Tracts ❑
N�JJ � ��''l �E City Boundaries"
� ❑ County Zoning
Multi Symbol _,,,,�;
❑ E911 Fire Districts ❑
I e � ❑ Fiood Panels f—I
� ❑ Flood Zones ❑
�" � � O Parcels ❑ I
�1! • i �.._ _; ,
:`, _ ❑ School Districts
����'�7►� Y � Multi Symbol , ._
�6��� . p N , ❑ Soils ❑
(y�/ � ` - � ❑ Town Zoning ❑ ,
;._ ,
:_.� ,� � ❑ Townships �!
� � � Multi Symbol .,u� '
❑ Voting Precincts ❑
Infrastructure �
�5� _ ._----_.�_ C' Driveways
� ❑ Rail Lines — li
� '' ❑ Street Centerlines — I
i
I` � C USINC Highways
�
+ �■�� /� Multi Symbol N:�;3
-' � l��� � US Highway— ,
SW �. SE NC Highway—
Parcel Data Interstate—
i �, Aerial �
Find Adjoinin<,Parcels Photography
• LandUnrt/Type:B700000001
Physical I
,  :/AC ❑ Creeks and Rivers —
• County ID. 6700000001 • Deed BooWPage:00197/0100 ❑ E911 Addresses �
• DeedDate:1997/08/28 n Fire De artments �
• Account Number:15452000 • Sales Price:$0.00 P
• PIN:5863234526 • Property Address: ❑ Schools � ,
• Legal 12.53 AC YADKIN VALLEY RD 001526 001526 RD
• OwnerName:CLAWSON ANNE WHITE Draw Layers �
• Counry Zoning:R-20
• Ownei/Address 1:CLAWSON ANNE WHITE • Census Code:
• Owner/Address 2:
• Ownei/Address 3:5004 KLONDIKE ROAD • City Code: I�l_�P Cul�ienC� �
• Fire Distnct:FARMINGTON
• City,State Zip:WALKERTOWN ,NC 27051 - . Flood Zone:ZONE X
9]27 This map is prepared for the
• Flood Community:370308 invento of real ro ert found
• Land Value:$41,220.00
• BUlldin ValUe:$32,840.00 • Flood Panel:0050 C within this jurisdiction,and is
9 • Flood Map Date:12-17-1993 compiled from recorded deeds,
• Ouf Building/Extra Features Value:$9,460.00 � plats,and other public records and
• Assessed Value:$83,520.00 Soil:Gn62 data.Users of this map are hereby I
• TOWnShI/�:FARMINGTON notifed that the aforementioned
• Property Record Card public pnmary iMormation sources
• TOWI1 Z0�/�9: should be consulted for venfication
• Voting Precinct:FARMINGTON of the information contained on this
• SChool DI'StIICt:PINEBROOK map me Davie Counry,mapping,
- � � - � and software companies assume no �.
legal responsibility for the �
information contained on this map or
in this website.
Data Effective Date:02
1 of 2 5/29/200� 2:01 PNf
) ���/�'�- ��-� � 1 S.
� �"�-
o, 2 ���
<,z aw �� s�� <,s �
(1.BOA
' 8350 �
��l � ^3
��
�
zio (4.4
6220 (743A) �°
5150
(5.84A)
2169
8
� i�
(s ozn)
�
0554 $ 1fi.81A) � .
8767 5 4
��ol
�09 z �Ays �23a0A I
mo� �
5 (3 24A)
3522
a�i �z �
]3] �p 302
I
�,� � �,s�' 1464
2300� a s3oi �,oan)
8238
NATALIES WAY � �,Zs�A,
z„ aas 62�0
0193
sss
x
ifa� _ �, zoe I
098� �
A8� s.000n �I
aos 2984
(9 04A) �
2622 asz
zs� �
I �5�8
(3 6�
s���3
� a�eon
s�s 364a
(223A) r
4526
ii� —
1532
� a� y� 313
\ 15�5
\ �z ean�
� s�g40 '� r�
� 1549
>,s 3�,
�
` (2.33A) ''
� - ���0
\ 'a� 0 1565�
\ �� (2.30A) �
� 20'��72
\ �z aan�
� R Z�g.�O ` 9920 S
� eao .�b
(65.79A)
3318 I � �z�g�$$ ` (a630A)
423 / s°aa
g / os 9 1604 °� �� ��e�az �
1 90 c,ean� 15
g 6636 �
(187A) $ �
0578 _
izos
7 �
(8.98A) ,�c� ��j Ili
0317 7�+� �
0
ns �m — I
� ' I6��
(4 26A) � �I,
1 a g 165�Qie� sozs „
� 1658 3032 g
I �,z
330
I �� ,
� $ 1664:��3 • ' • `
a I
I E`eJA (3.OSA) � +
I 97G7 i
3727 ^I
16�8
� »,
_ _ _ __ _ _ _
' � � , DAVIE COUNTY HEALTH DEPARTMENT
' � � � Environmental Health Section
� ' Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION I
Account #: 990003635 Tax PIN/EH #: 5863-23-4526 �
Billed To: Lawrence Davis Subdivision Info:
Reference Name: LocationlAddress: 1526 Yadkin Valley Road-27006 '
Proposed Facility: Residence Property Size: 2.23 acres Date Evaluated: �_���/�'y� _- I
l
Water Supply: On-Site Well Community Public �
/ �
Evaluation By: Auger Boring " Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e position c- �S
Slope % i ' r '
HORIZON I DEPTH �'r 5 � �
Texture grou ,���_ �
Consistence � S${- �;S
Structure 54�'� A 7)
Mineralo - ��
HORIZON II DEPTH ��'-: � '- � I
Texture rou �;(' ='C e� :
Consistence - _�
Structure � I
Mineralo �i�C ' �_ �lC,, �
HORIZON III DEPTH
Texture rou • F�, S,c
Consistence
Structure SQjlc
Mineralo �:
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS ii
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION II
LONG-TERM ACCEPTANCE RATE ,
SITE CLASSIFICATION: 6 " EVALUATION BY: ��� ` `�C''y'�"�
LONG-TERM ACCEPTANCE RATE: �����`�! '� OTHER(S) PRESENT:
REMARKS:
LEGEND
i.�ndscape Position I
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 clay loam SIL- Silty loam CL-Clay loam SCL- Sandy clay loam
SC- Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
D�is�
VFR-Very friable FR- Friable FI- Firm VFI -Very firm EFI - Extremely firm I
�
NS - Non sticky SS - Slightly sticky S - Sticky VS -Very Sticky
NP-Non plastic SP- Slightly plastic P- Plastic VP-Very plastic
S�I11�I11L�
SC - Single grain M- Massive CR-Crumb GR- Granulaz ABK-Angular blocky
SBK - Subangular blocky PL- Platy PR-Prismatic
Mineraloev
1:1,2:1,Mixed
lY4teS
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 DCHD OS/OS (Revised)