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189 Montclair Drive Lot 4Davie Countv. NC Tax Parcel Renort Wednesday. October 19. 2016 Parcel Number: NCPIN Number: Account Number: Listed Owner 1: Mailing Address 1: City: State: Zip Code: Legal Description: Assessed Acreage: Deed Date: Deed Book I Page: Plat Book: Plat Page: Building Value: WARININU: 'sills IS NOTA SURVEY Parcel Information F712OA0004 Township: Shady Grove 5860952686 Municipality: WILLIAM ELLIS 37216540 Census Tract: 37059-803 HOTH PATRICIA M Voting Precinct: WEST SHADY GROVE 189 MONTCLAIR DRIVE Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY R -A,1 -2-S NC Zoning Overlay: Freatures Value: 27006-0000 Voluntary Ag. District: No LOT 4 BALTIMORE HEIGHTS Fire Response District: ADVANCE Land Value: Total Assessed Value: 2.04 Elementary School Zone: SHADY GROVE 511997 Middle School Zone: WILLIAM ELLIS 001940843 Soil Types: MrC2,SeB 0006 Flood Zone: 076 Watershed Overlay: DAVIE COUNTY 233350.00 Outbuilding & Extra 1530.00 Freatures Value: 36000.00 Total Market Value: 270880.00 270880.00 9 ouµr� 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 n0 NC or arising out of the use or Inability to use the GIS data provided by this website. CONSTRUCTION AUTHORIZATION ° = Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Address: City: Statefzip: Phone #: / For Office Use Only "CDP File Number 231913-1 County ID Number. 5860952686 Evaluated For: EXPANSION ' �, Township: T VALID UNTIL: 1 1/ 3 0/ a 0 a 1 Patricia Hoth Property Owner: Patricia Hoth 189 Montclair Drive Address: 189 Montclair Drive Advance City: Advance NC 27006 State/Zip: NC 27006 (336) 918-7828' Phone #: (336) 918-7828 Property Location & Site Information Address/Road #: Subdivision: Baltimore Heights Phase: Lot: 4 189 Montclair Drive Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: 4 \ "Water Supply: PUBLIC Directions Hwy 158 East right on Baltimore Rd on the left Dann 1 ^f'A Minimum Trench Depth: 3 6 \ Inches Site Classification: Provisionary Suitable Saprolite System? QYes _ ONo Minimum Soil Cover. a 4 Inches Design Flow: - 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a Maximum Soil Cover: a 4 Inches "System Classification/Description: 'Distribution Type: PUMP TO GRAVITY TYPE III G. OTHER NON -CONY. TRENCH SYSTEMS Septic Tank: Gallons "Proposed System: 25% REDUCTION 1 -Piece: O Yes O N o Pump Required: QYes ONo OMay Be Required N Rrification Field 4 8 0 Sq. ft. Pump Tank: Gallons No. Drain Lines 1 1 -Piece: QYes ONo Total Trench Length: 1 a 0 ft GPM—vs— ft. TDH Trench Spacing: — 9 QInches O.C. Dosing Volume: Feet O.C. g _ Gallons Trench Width: 3 Inches Feet . Grease Trap: Gallons Aggregate Depth: inches - - Pre Treatment: ONSF OTS -1 OTS -II Septic Tank InstallerGrade Level Required: 01 011 OIII OIV Dann 1 ^f'A CDP File Number 231913-1 Repair System I County ID Number: 5860952686 ❑ Open Pump System Sheet ired:(DYes ONO ONO, but has Available Space *Site Classification: Provisionally Suitable Design Flow: 4 --8 0 Soil Application Rate: 0 - .1 7 5 *System Classification/Description: _ TYPE III G. OTHER NON -CONN. TRENCH SYSTEMS *Proposed System: 25%REDUCTION Nitrification Field 1 7 4 5 Sq. ft. No. Drain Lines 4 Total Trench Length: 4 3 6 ft. Trench Spacing: — 9 O Inches O.C. Feet O.C. Trench Width: Inches — 3 Feet Minimum Soil Cover. Aggregate Depth: _ inches Inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches *Distribution Type: PUMP TO GRAVITY Pump Required: QYes ONo OMay Be Required PreTreatment: ONSF OTS -1 OTS -11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department *Permit Conditions The issuance of this permit by the Health Department in noway guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System Construction shall bevalid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and may be Issued atthe sametime the Improvement Permit Issued (NCGS 130A -336(b)} If the installation has not been completed during the period of validity of the Construction Permit, the information submitted In the application fora permit or Construction Authorization Is found to have been Incorrect, falsified or changed, or the site is altered, the permit or Construction Authorization shall become Invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance; monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: Date: _ / / *Issued By: 2140 -Nations, Robert Date of Issue:. 1 1/ 3 0/ 2 0 1 6 Authorized State Aget: Malfunction Log OYes QHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 231913 -1 Davie County Health Department CDP File Number: 210 Hospital Street 5860952686 P:o.Box 848 County File Number: Mocksville NC 27028 Date: 1 1/ 3 0/ 0 1 6 Q Inch n Scale: OBloDrawing Drawing Type: Construction Authorization ON/A= ft. I : i � i " I j JI 1 I I { a I3 I S I I t I i.�� i � i! �� ►►� l _ CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: 231913 -1 P O B 84$ . a _ 5860952686 Mocksville NC 27028 County File Number: _ Date: 1 1/ 3 0/ 2 0 1 6 -Click bel w_to import an image from 'an external location: Drawing Type: Construction Authorization APPLICATION'FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health ,#PAID " P. .:Box 848/210 Hospital Street ,Mocksville NC -27028 D ., ( 1680 Rerelved , � (336G)753-6780/ Fax 336)753 P muF ❑ Authorization Application For: ❑Site Evaluation/Improvement � n To Construct (ATC) C�'Both Type of Application: ❑New System ❑Repair to Existing System dPxpansion/Modification of Existing System or Facility 'IMPORTANT' THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for.instructions ` APPLICANT INFORMATION , Name n l/b C Address IM City/State/ZIP Email Name on Permits Mailing Address if 1. f C mr—N rent than Above Contact Person Spire Home.Phone , Business Phone Email: PROPERTY INFORMATION v ' *Date House/Facility Corners Flagged / NOTE: A survey plat or site plan must accompany thisi application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with sin, no expiration with complete plat.) Owner's Name I A -T .t LjA Phon Number •3 Owner's Address 18 Q � 0J of , L `7, i City/State/Zip �� V A JV C 6 0!70 a4 Property Address<SAmCity _ Lot Size Tax PIN# Subdivision Name(if applicable) ft k Section/Lot# Directions To Site: Wh n/ / 1C t -v A4-! 7-7A-1 )rO ZYY» 1)7mtYOJ, t If the answer to any of the following questions is "Yes",supporting documentation must be attached: Are there any existing wastewater systems on the site? )(Yes _No Does the site contain jurisdictional wetlands? Yes XNo` Are there any easements or right-of-ways on the site? _Yes INo Is the site subject to approval by another public agency? _Yes No Will wastewater other than domestic sewage be generated? YesAN o IF RESIDE E FILL OUT THE BOX BELOW # People # Bedrooms #;Bathrooms 4C Garden Tub/Whirlpool ❑Yes ❑No Basement: '1 es ❑No Basement PI bing: 'Yes ❑No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers , #.Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested: accepted ❑Innovative ❑Alternative ❑Other -- Water Supply Type: CeCounty/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes (�o If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that permit(s) IP(s) or CA(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. Permits issued will expire 5 years from the date of issuance. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging or staking the house/facility location, proposed well location and the location of any other amenities. Ap licant's Signature 13�7 /4J, IL operty owner's or owner's legal representative signature Date Revised 11/16 Site Revisit Charge Date(s): Client Notification Date: EHS: � 1z Account # GJ Invoice # DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee s -Name: %rl !r"�' r. ��,.,., Subdivision Name .t.; Directionslo property: a Section: Lot: IMPROVEMENT PERMIT Tax Office PIN:#-�) ;} r'<'' fl Road Name �` (.�� I t C c:,. i Zip: **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/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) 41, ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE Aj # BEDROOMS 7— # BATHS 12- # OCCUPANTS "? GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT ,/ # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE � ." �- TYPE WATER SUPPLY C' DESIGN WASTEWATER FLOW (GPDJ�� l/ NEW SITES AIR SITE SYSTEM SPECIFICATIONS: TANK SIZE��GAL. PUMP TANK GAL. TRENCH WIDTH = ROCK DEPTH' LINEAR FT. /L/? J OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT 1 J 00 I v dmipo ),w . , /tv **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: C for U r AUTHORIZATION NO. IlSi OPERATION PERMIT BY: At// DATE: /S~!O **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) A APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department Environmental Health Section 7,f V7 P.O. Box 848 l� b .a �l �0 �, Mocksville, NC 27028 pd '�� (704) 634-8760 r t ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REOUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Ci a & Mailing Address -/12, IV41 p -/W A City/State/Zip ei,c� w AJ C--, a 702 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: [ ] Site Evaluation Contact Person Home Phone Business Phone City/State/Zip [ ] Improvement Permit & ATC [ ] Both 4. System to Serve: [4Mouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms -Y-2 # Bathrooms [,gbishwasher [ ] Garbage Disposal [,i]'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: [J County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [,+No If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** AXIAMOF THE PROPERTY MUST BE � i' % U�P 4) SUBMITTED WITHrS APPLICATION. Ig roperty Di ensi ns: � � WRITE DIRECTIONS (fmmcksville) TO PROPERTY: dK Tax Office PIN: ' # .15Y6 0 - - 15-9 662S'' /� 11k�ka� Z6 Property Address: Road Name D /-2K Q.�i�l Mane 64 Z 011 � City/Zip _ ... �/ E' ; / 2� 2491 �, DWI L -e9 f If in Subdivision provide information, as follows: Name: B zh,'I't (7lkp- 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 [.K. & X4Z to duct all testing procedures as necessary to determine the site suitability. DATE Revised DCHD(6-96)-ao'L�� THIS AREA MAY BE USED 31,�3 W04'93) C07.S s 11V F4 BukZ-£W.J R,1�,gae— FOR DRAIVINCC IIOUR SITE PLAN: Gds of 0Fe.s '1�7�?p 5:gusTi eb m'ak L-06-o5od 4F;husk . �. has been `found to comply - Regutot,ons. w)I the„ .excel any, as ore r.oted, in the` Board and thct it has .b^ ►.n the office of the Regis; noted thot ,.uch opprovoif include aPProvol to.' ►ns{ focihtes nor does it ►ne. construction or occuponc4 Director,' DnviC Gbuni of _ PA RT. 0 F PARCEL 18.04 S.TA C . L EE'.. MYERS D. B, 151- 779 , I S'89°50--50 ''-E _ ry 98.05 - ----__ ---- .198 05` - -=�--- - --- ig8.p5 -- -- - (38:26 foE> 5 negot ive dr►vevby eosernent— =LO �LO rn Q1 0 oCQ Two ACR Es' 10 utility I easement ; 198.05 - - - --`- - - -98.05 - - --- - - -- 198.05 - - --� --_-- - ,98.(. DO ^25 4 Totoi '1,586.93 g' i,'5 8 5-7 6 ' S 890- 50 .-25 E -.- -�Lo IJ:O�_ - - --- - lg`8.05� ---_ ___� I98.05�_ -_ _ _�..._ 198 ; Ut►!,,ty easem,er 3 O -� ISO a. ' rn W _ 0 0 O 0 N O -- t/ O O l,oa 5 n_egoi.►vc driveway easemE nt--/ 36► •198.05 t 198.05 I No. of People Served No. of Commodes No. of Lavatories No. of Sinks _ No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: Public ❑ Private 8. Property Dimensions LOA-IC-�) l'- c� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? ❑ Community "NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: This is to certify that the information provided is correct to the best f my knowledge, an( incurred from this application. / l DATE -�-- f ,TUBE Y tt I am responsible for all charges CONSENT FOR SITE EVALUATION TO BE`DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 0`2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative f the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to a ermineliaid)site's suitability jorr d absorption sewage treatment and disposal syst M. ATE __.,.,-- ATURE DCHD (12-90) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 r Mocksville, NC 27028 1 moi% i 1. Application/Permit Requested By Mailing Address �� ,�,['y'%�?c�ci`�1� Ca�.� �'y(�f�s✓� i='� �/�' Z%` I✓ I Home Phone Business Phone 7 6.9 c) 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation ❑ Septic Tank Installation 4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision /s%"e _-Z2 >'i Section Z_ Lot # ❑ Basement/Plumbing�04 O No. of People ❑ Basement/No Plumbing )A i' No. of Bedrooms r; ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks _ No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: Public ❑ Private 8. Property Dimensions LOA-IC-�) l'- c� Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If yes, what type? ❑ Community "NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: This is to certify that the information provided is correct to the best f my knowledge, an( incurred from this application. / l DATE -�-- f ,TUBE Y tt I am responsible for all charges CONSENT FOR SITE EVALUATION TO BE`DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 0`2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative f the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to a ermineliaid)site's suitability jorr d absorption sewage treatment and disposal syst M. ATE __.,.,-- ATURE DCHD (12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section'YN Soil/Site Evaluation NAME DATE EVALUATED d' - ADDRESS,,,,PROPERTY SIZE f�G PROPOSED FACIILTY _lxaarr LOCATION OF SITE Water Supply: On -Site Well Community Public tom' Evaluation By: Auger Boring Pit t/- Cut FACTORS 1 2 3 4 Landscape position L .L Sloe % HORIZON I DEPTH Texture group Consistence Structure MineralogX HORIZON II DEPTH Texture groupG Consistence ; Structure 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: �EVALUATED BY: X6 /Z LONG-TERM ACCEPTpa_a' E RA REMARKS: sl/ DCHD(01-901 OTHER(S) PRESENT: LEGEND Landscape Position R -Ridge S -Shoulder L -Linear slope FS-Footslope 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 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 Mi neraloBY 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 watef 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 No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: Public ❑ Private 8. Property Dimensions 0A"C-- A.( '26 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If vac_ what tvna? ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: � ?" This is to certify that the information provided is correct to the -best f my knowledge, anc incurred from this application. 7 DATE 1/ TURE I am responsible for all charges CONSENT FOR SITE EVALUATION TO BE'15_0NE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. p'2. I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representativef the Davie County Health Department to enter upon above described property located in Davie County and owned by %?•rJ. Zc: to conduct all testing procedures as necessary to a ermine" said ite's suitability Jor d absorption sewage treatment and disposal syst m. Z 4 I -f ATE—eStPa ATURE DCHD (12-90) k APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 1. Application/Permit Requested By i�7lG �4-c.. 6'lpI Mailing Address �u �� C / Cl / L%r .n: /C�,_ .�/ � Z• 7ez, 6 Home Phone i -,. Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: ❑ General Evaluation ❑ Septic Tank Installation 4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision Section Lot # ❑ Basement/Plumbing Old No. of People ❑ Basement/No Plumbing OP �A•� No. of Bedrooms ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers Water Usage Figures 7. Type of water supply: Public ❑ Private 8. Property Dimensions 0A"C-- A.( '26 Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If vac_ what tvna? ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: � ?" This is to certify that the information provided is correct to the -best f my knowledge, anc incurred from this application. 7 DATE 1/ TURE I am responsible for all charges CONSENT FOR SITE EVALUATION TO BE'15_0NE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. p'2. I DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representativef the Davie County Health Department to enter upon above described property located in Davie County and owned by %?•rJ. Zc: to conduct all testing procedures as necessary to a ermine" said ite's suitability Jor d absorption sewage treatment and disposal syst m. Z 4 I -f ATE—eStPa ATURE DCHD (12-90) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section p d' Soil/Site Evaluation NAME DATE EVALUATED !` ADDRESS PROPERTY SIZE PROPOSED FACIILTY ,'e"2j'1f e— LOCATION OF SITE Water Supply: On -Site Well Community Public L---' Evaluation By: Auger Boring Pit !l Cut FACTORS 1 2 3 4 Landscape position I<r Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure 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: �`'� EVALUATED BY: ,Ala"� 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 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) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 NOONM'M'MMMMMENEEM"OM ■■■...■■.\.■■■■..■..■..\.\..\.......■■..�....■■�■�..■....■... ■■ ■■■...■■■iii.X11/%■■■■■■■■■■■■■■■■■■■■■■■.■..■...■..■ ■■MMM■MMMMM■■■I .................................................... ......... ... .........................■...... ■■E■■■■. ...................... ........uE■.■■.■.■.■.■■E■.■■.E■..................CH■........NMI ■ SOMEONE NESEEN ...............■...................... 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DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION----,/ Soil/Site Evaluation APPLICANT'S NAME An 4 DATE EVALUATED Z-11 1 2 j 7 PROPOSED FACILITY 4 ( a PROPERTY SIZE �1� SUBDIVISION +f P �`j�t° Q /' ROAD NAME /Y'/Oy✓Tiii Water Supply: On -Site Well Community Public 1/ Evaluation By: Auger Boring Pit V/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % HORIZON I DEPTH Texture groupti L Consistence Structure Mineralogy HORIZON II DEPTH S/O t Texture group CC Consistence -r,- ,Structure Structurek 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: 4 LONG-TERM ACCEPTANCE RATE: ��• S REMARKS: s'LiS Ili �fNS '/,02 0/L all - Cy "LEGEND lr EGEND DCHD (01-90) EVALUATION BY: OTHER(S) PRESENT: `dL 4-W 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) LTAR - Long-term acceptance rate - gal/day/ft2 ■ ■■ ■■ ■EES■ ■E■■■ ■E■E■ NOSES ■ENE■ ■■■E■ ■■■E■ ■■E■■ ■E■■■ ■ENE■ SEMEN 2E■E■ ZME!RN MEM■■ ■■E■ MEMO OMEN JM■MUMM■MMO■■■■M■■MEM■■N■ MOON ■ENE■■EN■EME■■■NEE■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■E■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON■"It■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ NOON ■■■■■■■■■■■■■1.IP.7■■■■ ■O■■ ■■■■■■■■■■■■■IrE7■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■EMM■■ ■■MEM■ ■■ME■■■ ■M■■ME■ ■MEM■■■ ■■M■EN■ ■MMMEM■ ■NNEEM■ ■SME■E■ ■NM■■E■ ■N■■■■■ ■■■ME■■ ■NM■■M■ ■■■■■■■■■■■■■■NOON/■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■�■■■■■■■■■■■■■■■■■■■■■■■/NOON■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/NOON■■ ■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/NOON■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■/■■■■■■■■■■■/NOON■■■ ■■■■■■■■■■■■■ NOON■/■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■NOON■/■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■/NOON■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ Davie County Health Department and Home Health Agency Environmental Health Section P.O. BOX 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKSVILLE, N.C. 27028 - PHONE: (704) 634-8760 August 1, 1997 Patricia Hoth 1061 Riverbend Dr. Advance, NC 27006 Re: Site Evaluation(s) Baltimore Heights/Lot 4 Dear Ms. Hoth: This letter is regarding Lot 4 in Baltimore Heights. Lot 4 is clas -'L i provisionally suitable for the installation of a septic tank system on the extreme upper right side. A pump would be required in order to place the drainfields in provisionally suitable soil; however, if there is suffieient provisionally suitable soil on the back right side a pump might not be needed. In order to make that determination a more detailed evaluation needs to be done. Backhoe pits will need to be dug on the back right side of this lot to determine if there is enough good soil to install a system. If you have questions, feel free to call. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/wd v Davie County Health Department and Home Health Agency Environmental Health Section P.O. BOX 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKSVILLE, N.C. 27028 - PHONE: (704) 634-8760 August 1, 1997 Patricia Hoth 1061 Riverbend Dr. Advance, NC 27006 Re: Site Evaluation(s) Baltimore Heights/Lot 4 Dear Ms. Hoth: This letter is regarding Lot 4 in Baltimore Heights. Lot 4 is clas -'L i provisionally suitable for the installation of a septic tank system on the extreme upper right side. A pump would be required in order to place the drainfields in provisionally suitable soil; however, if there is suffieient provisionally suitable soil on the back right side a pump might not be needed. In order to make that determination a more detailed evaluation needs to be done. Backhoe pits will need to be dug on the back right side of this lot to determine if there is enough good soil to install a system. If you have questions, feel free to call. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/wd .Oavie County Health Department andHome Health Agency Environmenta(Heafth Section P.O. Box 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKSVILLE, N.C. 27028 Patricia Roth 10bl Riverbend Dr. Advance, NC L"ILAIciL, De, ar Ms. Hoth: 1. Un beptemoer li, Heights. ba5eu on the !,oil consitions on lot 4, this office classified the,-fot provisionaiiv suitable tar the instat'lEltl0n of a, septic tank system; hoWever, if there is plumbing - in the basement , , a pump will be required. The system must, go on the upper right side in the r -bar at the nouse. If you have questions, teel tree to call. RH/wd Enclosure