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111 Montclair Drive Lot 1IF Davie County. NC Tax Parcel Report Wednesday, October 19, 2016 Parcel Number: NCPIN Number: Account Number: Listed Osmer 1: f0ailing Address 1: City: State: Zip Code: Legal Description: Assessed Acreage: Deed Date: Deed Book ! Page: Plat Book: Plat Page: Building Value: WAFvN1I-N1G:Tff-I1S IS PilUTA SURVEY Parcel Information F712OA0001 TovrrshIp: Shady Grove 5860853698 Municipality: WILLIAM ELLIS 82519396 Census Tract: 37059-803 OGLE BRYAN A Voting Precinct: WEST SHADY GROVE 111 MONTCLAIR DRIVE Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY R -20,1-2-S NC Zoning Overlay: DAVIE COUNTY QD 27006-7096 Voluntary Ag. District: No LOT 1 BALTIMORE HEIGHTS Fire Response District: ADVANCE Land Value: Total Assessed Value: 1.02 Elementary School Zone: SHADY GROVE 8/2002 Middle School Zone: WILLIAM ELLIS 004340385 Soil Types: EnB 0006 Flood Zone: 076 Watershed Overlay: DAVIE COUNTY 148970.00 Outbuilding « Extra 41600.00 Freatures Value: 36000.00 Total Market Value: 226570.00 226570.00 wv Davie County, All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the 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, is agents, consultants, contractors or employees from any and all claims or causes of action due to p UNC NC or arising out of the use or inability to use the GIS data provided by this website. j HEALTH DEPARTMENT RELEASE �yA �SYA7F o Davie County Health Department 210 Hospital Street - P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Bryan Scot Ogle Address: 111 Montclaie City: Advance State/Zip: NC 27006 Phone #: (336) 998-5779 PERMIT VALID 0 6 a 4/ a 0 1 9 UNTIL: Property Owner: Bryan Scot Ogle Address: 111 Montclair City: Advance State/Zip: NC =Phone (336) 998-5779 27006 Property Location & Site Information Address Montclair Drive Subdivision: Baltimore Heights Phase: Lot: 1 Road # Advance NC 27006 — SINGLE FAMILY Township: *Structure: Directions # of Bedrooms: 3 # of People: Hwy 158, right on Baltimore Rd. Left on Montclair *Water Supply: PUBLIC Type of Business: Basement: F -]Yes � No Total sq. Footage: No. Of Employees: *Proposed Improvement: Pool and Storage Characlem Remaining 750 This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: *Date: / / *Issued By: 2140 - Nations, Robert *Date of Issue: 0 6 / a 4 / a 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** Hand Drawing O ImportDrawing Drawing Type: HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Health Department Release CDP File Number: 139287 - 1 County File Number: F7-120-Ao-001 Date: 06 /.2 4/.1 0 1 4 0 Inch Scale: 0 Block = ft. 0 N/A HEALTHDEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Type: Health Department Release Page 2 of 2 CDP File Number: 139287 - 1 County File Number: r -7-120-A0-001 Date:. 0.6. / a 4/ a 0 14 Davie County Health Department 04c-4) PA lvironmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 tr Mocksvillc, NC 27028 I'hone: (336) - 7.53 - 6780 Far: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: 11 A% SC.o 04 1 jL Phone Number -216 -r77 (Home) Mailing Address: M Mi oa 1 r 1� f 33 6- 77 3" 773 (Work) %k0k %/ 4 N Gc, f (QC- Z? O D k, Detailed Directions To U,Jnl rl of,� LJ►i . F1rSl D., 1It� Property Address: oNr a 1 r" " • Ay a nJ C e. Please Fill In The Following Information About The EXISTING Facility: FI -170-44-00t Name System Installed Under: J. FMN(i1C. nnrrl8 N Type Of Facility1,41 : Date System Installed (Month/Date/Year): )9'/200 Number Of Bedrooms: Number Of People: 3 Is The Facility Currently Vacant? Yes ( o If Yes, For How Long? Any Known Problems? Yes (SO)If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: 11-4 N t M S Number Of Bedrooms: Number of People Pool Size: )C.qL Ft- Garage Size: Other: Requested By: An— � Date Requested: Z 3 (Signat r For Environmental Health Office Use Only Disapproved ,/ / ,�Q � � �-C� ISS 5 -le / L." �S Cil")OCA n 1511/ � /� l(c`�'e� Environmental Health Specialist � s��/�/� _� Date: ��, i,T 5e _? *The signing of this form by the Environmental Health Staff is in no Mended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment` Cas /� { Check xMoney Order # Amount:$_ Paid By: 2, uq (6 Received By: Account #: �%,G� 2 5(% Invoice #: &,1A --- —Date:- 1 tdEGANS',`VAY _ 198, 196 I x 36 Pio ; 05 0 k i Z I Q CSI lS� IT 200 It��ff- �lat- N 98 N 11 M� t(� a� ,^)r ` T et ! tftl'pRf1 i rESSga qfi 'TRS dd OPe�f All data is provided as is without warranty or guarant o an ki ped I fig but not limited to the implied �y� warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of O b 1A Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of Printed :Jun 23 2014 5 the use or inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000804 Tax PIN/EH #: 5860-85-3698 Billed To: Ronald Nichols Subdivision Info: Baltimore Heights See. 1 Lot # 1 Reference Name: Ronald Nichols Location/Address: Montclair Drive -27006 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2189 **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 STTE 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: Z< Garbage Disposal: ❑ Commercial Specification: Facility Type Washing Machine: e Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) Oo/-D Site: New e Repair ❑ � System Specifications: Tank Size,&V? GAL. Pump Tank GAL. Trench Width -,,?P"Rock Depth 146N � Linear Ft�p6 Other: 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 in. on the day of installation. Telephone # is (336)751-8760.**** V r - Environmental Health Specialist's Signature: - , Date: DCHD 05/99 (Revised) Account #: 990000804 Billed To: Ronald Nichols Reference Name: Ronald Nichols Proposed Facility: Residence ATC Number: 2189 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5860-85-3698 Subdivision Info: Baltimore Heights Sec. 1 Lot # 1 Location/Address: Montclair Drive -27006 Property Size: 1 Acre 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: ? A� r)�� Date: /yz Im 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 as a guarantee that the system will function satisfactorily for any given period of time. Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: APPLICATION FOR SITE EVALUATIONAMPROVEMENT . & ATS - - ' J Davie County Health Department IE ow IE Environmental Health Section D oll'1 P.O. Box 848 JAN 2 4 I:C'3 U I Mocksville, NC 27028 !� (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed &n a Ild 1 `1 1 c,-ko � S Contact Person6fLi hi A W CL O K Mailing Address I Q S W -I k 1 i CLL -' -3 Home Phone Q� 2` i g I y City/State/Zip 2. Name on Permit/ATC if Different than Above Mailing Address .7 q ity/State/; 3. Application For: [Site Evaluation [ Improvement Permit & ATC Phone [ ] Both 4. System to Serve: [VHouse [ ] Mobile Home [ ] Business [ ] Industry [ ] Other 5. If Residence: # People # Bedrooms_ # Bathrooms Dishwasher [ ] Garbage Disposal [VjWashing Machine [rjJ Basement/Plumbing KBasement/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: M 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 **'yX4Th�'T OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: (� 'Cr e. WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # 5S & Q_ - SS - 3(o W i 5 A fOLOCL f -A Ad vc(Are C Property Address: Road Flame M 0 n4 -f- f a t t er r', y C � C -�--V U N P, -) f V:1 m ore 2 0 a d City/Zip AdolC,ACC IiiC *D -7©0(n ; k�� \h1�o ��i�kk" MatC If in Subdivision provide information, as follows: �I gr I n+ or) ) e -U- Name: E aV�\rnm-L Section: I 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 TQM Ai\u V<v I L Si�rj to conduct all testing, procedures as necessary to determine the site suitability. DATE SIGNATURE` 1 6, I C Revised DCHD (06-96) THIS AREA %fAJ $E USED FOR bRAIVINC YOUR SITE 1'LAN: 1 -ro" -- -O J r - SEP 29 1999 ��1 V �r 1 z� V %0X10 S I 1 SEP 29 1999 ��1 t 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 C, y Mailing Address / �'y'�'_��1� Oall-Y 41-,,%(/.2T./c e- t/'C-- Z- Zees 6 Home Phone .iv ` yV Z, Business Phone 2. Name on Permit if Different than Above 3. Application/Permit for: Z General Evaluation ❑ Septic Tank Installation 4. System to Serve: OlHouse ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision l %//'��"-��%J cell TjSection Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing 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 'P 7. Type of water supply: pubBC ❑ Private 8. Property Dimensionsy�Jc /► �'- �% Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If vac what hina7 M ❑ 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. 71 J DATE f TURE 4 Cc /24rs S I am responsible for all charges CONSENT FOR SITE EVALUATION TO BE`60NE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. E'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 crefermine saidsite's suitability fo d absorption sewage treatment and disposal syst m. ATE ---SIG ATURE DCHD (12-90) -4- ~' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section , - Soil/Site Evaluation NAMES /ski/ ADDRESS PROPOSED FACIILTY lflellet0 DATE EVALUATED PROPERTY SIZE f/IG LOCATION OF SITE�n>o/� Water Supply: On -Site Well Community Public L� Evaluation By: Auger Boring Pit 1 Cut HORIZON I DEPTH FACTORS 1 2 3 4 Landscape position J_ - Slope Z HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure e / 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 RATEI SITE CLASSIFICATION: ,(OT EVALUATED 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 Moist VFR-Very friable FR -Friable FI -Finn 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/f12 DCHD(01-901 IS iiiiiiiiiiiiiiiiiiiiiiisiiiiiiiiii=iiiiiiiiiiiiiii�■'iiiiiiiiN■i=� .....................N■■■■■■■■■■■■N■■■■■i■■■.■■.■■■�■■■■■■■■■■.J .....................■N■■■■■■■.■■■■■■.■■■■■■■■■■■■■■ ■■■N■■■■■■� iiiiiiiiiiiiii■iiiiiiiiiiiii�■iiiiiiiii'■■'�iii�■ii�iii■N MEMi■■iiiiii■ �iiiiii"iiiiiiiiiiiiiWiiiiiii�"""�i""" ....................................................■■...o...■■.■. .....................................■ ..�.....■ ■ .:■:.■.:..:■:.■.:■.:■i.■■i.■i■■iiui■:■:■■.i■.i■■i■■i■■i■.i■■i■■i■■i■■�■i■■■■■■.■.■■■.■.■.''■■■■■ .. . .■■■■I■■■■■.■■ ■■■■■ ■■■■■■■■ EN0� i�=' iiIiiiiiiiiMEMEMiN o i ■iii ■■. u■.■ MEMORIES .................................■_:_:J ' :' ' 0M1 No '::::::. .................................. ... ■■■■■■N■■■■■■■■■■i■■.....■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■.■■.■ ■■■■■u■■.■ ..■■.■■■■■■■■■■■ ■■■■■....■■■■■.■■■■■■■■..■■■....■...�■■■.�. .. ■...■■■N■.■■■ :::::::qIMMIMMMEMEM_::::::: ::::::'..C�:0 ' '::'.::::=:a:N ..................................... ... �■MEMO.■ :C■■.. ■■■■■■.■■. ...............................!■■■■u�■.■�C■■■■�■■■■■■M■■■N ■■ MOM MMEMMEMM MEMMOMMI ■■■■.■■■■■■.■.■■■■■.■■■■■■■■■■■■■■■.■■ MEMO ■■■■■■■■■■.■■■■■■■■■■■...■■ N ■ ■ ■iiiiiiiiiiiiiiiiiiiiiiuiiii ■ ■■■.■■■■.■■■.■■■■■■■...■.■■■.. .■■■■.■■■..■....■■■■■■■■.■■■ ■■■■ ■.■■■.■■■.■■.■■.■...■■■■.■■■■■■N■■■■■ i■.■■■■■■■■■■■■■■■■■■..■■■■ DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section SECTION._ LOT -1 ' r Soil/Site Evaluation APPLICANT'S NAME PROPOSED FACILITY SUBDIVISION Water Supply: Evaluation By: On -Site Well DATE EVALUATED C / ✓?Z PROPERTY SIZE ROAD NAME/J` i` ✓v` sem/ Community Public &1__11' Auger Boring Pit Cut FACTORS 1 24 3 1 4 5 6 7 Landscape position Slope % HORIZON I DEPTH it Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG Consistence Structure h / 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: e5; %d el �``�/�' "EVALUATION BY: LONG-TERM ACCEPTANCE RA' f REMARKS: DCHD (01-90) OTHER(S) PRESENT: W 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 ■■mons ■■■■E■ ■■■■E■ ■■■■E■ ■■mm■■ ■■■SO■ ■E■EM■ ■E■■O■ ■E■■E■ ■■MONS ■■EEE■■ ■■■m■■■ WOMEN= RNME■M■ Nom■■m■ ■amosms ■E■ESE■ ...om.. 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Davie County Health Department i and Home .wealth Agency Environmenta(Health Section P.O. Box 848 / 210 HOSPITAL STREET COURIER #09-4-06 MOCKSVILLE, N.C. 27028 PHONE: (704) 634-8760 February 18, 1998 Ronald Nichols 195 Williams Rd. Mocksville, NC 2708 Re: Site Evaluation Baltimore Heights I/Lot 1 Tax PIN: #5860-85-3698 Dear Client(s): As requested, a representative from this office visited the aforementioned site on February 12, 1998. Based upon the information provided on the application for site evaluation and after the evaluation was completed, the site was found to be provisionally suitable installation of an on—site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, Robert B. Hall, Jr., R.S. Environmental Health Specialist RH/wd Enclosure(s) �. APPLICATION fOR SilE BIALUA I ICV/ifi S-iIUVBIEN I f� Davie County Health Department En vironmen tat Heath Section f P.O. Box 848/210 Hospital Street [I 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. _T 1. Name to be Billed -/ tt y ( �J/1�N T 2� 1Z Jit • Contact Person Mailing Address c� /3 u iV • -c /ct "t P'z Home Phone U 2 City/State/ZIP ���t �//� /L C e /1%! ;7 UC' 4< Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: 2"gite Evaluation ❑ Improvement Permit/ATC Il Both 4. System to Service: "ouse ❑ Mobile Home ❑ Business Cl Industry IJ Other 5.If sidence: #People ft Bedrooms #Bathrooms h Dishwasher LI Garbage DisposalI ashing Machine 1.1 Basement/Plumbing II Basement/No Plumbing 6. If Business/Industry/Other: Specify type # Commodes # Showers # Urinals # People # Sinks 4 Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: 4l County/City L1 Well IJ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �\No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Eithcr a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Properly Dimensions: WRITE DIRECI70NS (from Mocksville) to PROPERTY: Tax Office IN: # S S S C/3 ,d I Property Address: Road Name Ur , ✓ t City/Zip �aJy • 2?0 o G If in a Subdivision provide information, as follows: Namc: I� Section: Block: Lot: Date Properly Flagged: 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 airy responsible for all charges incurred front 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 to conduct all testing procedures as necessary to determine the site suitability. DATE ` G SIGNATURE/ THIS 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). A L/ )._� a i f A Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: EI -IS: Account No. ��— Z - Invoice No. O C DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002232 Billed To: Guy Comatzer Reference Name: Proposed Facility: Residence Water Supply: Evaluation By PROPERTY INFORMATION Tax PIN/EH #: 5860-95-1543.01 Subdivision Info: Baltimore Heights Lot # 1 Location/Address: Montclair Drive -27006 Property Size: see map Date Evaluated: ;%,*'- g>*'-ee On -Site Well Community Auger Boring Pit Y Public Cut FACTORS 12 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH, Texture group Consistence / Structure L �' 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: /J� EVALUATION BY: LONG-TERM ACCEPTANCE RATE: i 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 05/99 (Revised) No ME ■■ ME ■■ ■■ ■NM■■■ ■■■■■■ ■■MONS ■■■■■■ ■E■M■MEME■MEM■ ■EEMM■M■E■E■■■ ■■■MM■M■MMM■■■ ■EME■■■■M■■EM■ MEMM■■N■■■ENN■ ■■■■■MME■■■EN■ MMM■■N■M■MM■■■ ■■■■■■■■■■■■■■ MMM■■MN■■■■NN■ ■■■■■■■■■■NMN■ ■■MENS■■■■■MEM ■■■NN■■■■■■■M■ ■■■MEMS■■■■E■■ ■M■M■EME■■MME■ ■■■■■■■MESO■■■ ■ ■ ■ ■ ■■EM■■EMEM■■ M■S■N■■■NO■■ ■■■MNN■■■■■■ NE■■M■■EMMO■ ■■■■■■■■■■■■ ■■■■■■■OMs■■ ■■MMM■■■■■■■ ■E■■E■■MMM■■ ■■■■e■■M■■■■ ■■■ME■■■■■■■ ■■EMM■■■■MM■ ■■MMNNNN■M■■ ■■EEE■■■■■EE■EEMEEE■EE■■■■■ME■■■■Mee■■E■■■�i ■M■■■ME■EEE■ME■■■s■■■■■■Mee■■■■■■■Mee■■■■■ ■M■■■■■■■E■■■■■M■■■■■Mee■Mee■■■■■■■M■■■■■■ ■■■■■■e■ ■■■■■■■■■■■E■■■■■■■■■E■■■■■■MMM■ ■■■■■■■■■■■■■■■■Mee■■■■■M■■■■■■Mee■■■■■■E■ ■EE■■■MMM■■■■■■■■■■Mee■■■s■■EMMMEs■E■■s■s■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■MM■■■■ME■■■MMM■■■■E■ME■■EEEE■M�E■E■■EM■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■E■■■■■E■ME■MEM■EE■M■■MMM■■Mee■■M■■M■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ HEMENNE EMEMEMMEMNONMENNENEMENES ■■■■■E■■■■■■■■Mee■■■■■■■■■■M■■■■■■■■■■■■■■ ■■M■■■■■■■■■■■EME■MM■■MM■■Mee■■■M■■■■■■■■■ i■■■■■■■■ ■E■■■■Mee■■■■Mee■Mee■ME■■■■■■MM■ i■■■■■■■■■■eee■M■MM■■■E■■M■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■Mee■MMM■■■M■■■■E■■■MMMMM■ �i■■■S■■■■�■■■■■M■■■M■■eee■■■■■■M■■■■■■■■■■ ■■■■■■■■■■■■■■■E■ME■■M■■■■■■■■■■■■■■■■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ i■■■■■■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ i■■■■■■■eee■■■■■sE■M■EEM■■■sE■E■■■■■■■■■■■■ i■■■■E■■■■■■■■ME■MM■■■■■■■■■■■■■■EM■M■■■■ i■■■■■■S■■■■■■■■MM■■■■■■■■■■■■■■■■■■EMM■■■■ i■■■■■■■■■■■■■■■■MMS■■■■■■■■■■■■■■■■■■■■■■■ i■■■E■■E■■■■■■M■■■■■■■■MME■■■■■■■■■■■■■■■■■ i■■■■■■■■■■■■■■■■■■■■■■Mee■■■■■■■■■■■■■■■■■ i■■■■EEE■■MME■EM■■Mee■■MMEMME■E■■■■■■■ecce■ i■Esse■■■■eee■■■Es■ss■■e��e■■eee■ssss■s■s■■ iEEMM■■■■EMMEE■■■■■■■Meese■■■■■■■■■■■■■■■■■ i■■■■■M■■�i■■■■■MMM■■■N■E■■ME■■■■■■■■■■Me■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 989900215 Billed To: J. Franck Construction, Inc. Reference Name: Proposed Facility: Residence ATC Number: 2751 Tax PIN/EH #: 5860-85-3698 Subdivision Info: Baltimore Heights Lot # 1 Location/Address: Montclair Drive -27006 Property Size: see map 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 N TRUCTION I-SVALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: �- G�-� Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall ind has been installed in compliance with Article 11 of G.S. Disposal Systems," but shall in NO WAY be taken as a given period of time. Septic System Installed By: on Improvement/Operation Permit 900 "Sewage Treatment and will function satisfactorily for any Environmental Health Specialist's Signature: ,l�it� Date: S 3/ - is DCHD 05/99 (Revised) •DAVIE COUNTY HEALTH DEPARTMENT _ Environmental Health Section _ P. O. Bog 848/210 Hospital Street Mocksville, NC 27028 (336)7.51-8760 IMPROVEMENT(OPERATION PERMIT Account #: 989900215 Billed To: J. Franck Construction, Inc. Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5860-85-3698 Subdivision Info: Baltimore Heights Lot # 1 Location/Address: Montclair Drive -27006 Property Size: see map ATC Number: 2751 **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 -:&5 Dishwasher Garbage Disposal Washing Machine, -,2r-- Basement w/Plumbing)21 Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) ,76`0 Site: New,12, Repair ❑ System Specifications: Tank Size, a GAL. Pump Tank Other: Required Site ModificationS/C011UMU115. GAL. Trench Width �� Rock Depth 'Linear Ft,.,5:i9e9 / 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 1:30q. P.ont e day of installation. Telephone # is (336)751-8760.**** ISI p Environmental Health Specialist's Signature: Date: ^� - DCHD 05/99 (Revised) Y rACpAI N FOR SITE EVJ:LUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department — --a r. 104� Environmental Health Section V\P.0. Box 848/210 Hospital Btreet JAM 3 1 iMocksville, NC 27028 (336) 751-8760 ***ZJVOR2VM** THIS APPLICATION Cy1Nwr BE I'ROG'7EBBJW UNLESS ALL THE EQBT n=RMATION IS PROVIDED. Refer to the INIrO MMICH BULLETIN for instructions. 1. iter to be exiled t% Y-c;a. n C /C s I Contadt person Ts Ga - . h c, ltailinp Address '`7e/ 7 CP;X-e saw phone City/state/sip ._�%�� c rf"r V*' 44C A/r— Business phone - a !x $ 9pas38 2. ►tar on permit/ATC it Different than Wiliap Address 3. ]Application tor: O'Site Evaluation /City/state/min �Or1"rovemeat Fermi 4. system to service a I(House 0 Mobile Roma OBus a due s. If Residence: f people �_ # Bedrooms 3 I7 Dishwasher O ap Oasbe Disposal Vwasbing X dhiae 04",aant/plumbiaq 6. it suaiues•/2ndustry/Other► opwAry type f Commodes O Both iry 0 Other LIfY I Bathrooms O Dasemeat/110 piumbiaq / people i sinks I showers # urinals # water Coolers I! It=SERVICE: # Seats Estimated Rater Usage (pailons per day) 7. Type of water supply: County/City 0 Well 0 Community a. Do you anticipate additions or expansions of the faefilty this system Is Intended to serve? 0 Yes "o If yes, what type? ***1MP0RTAN'1'*** CLIENTS MUST COMPLETiETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESVBMITTED by the client with THIS APPLICATION. Property Dimensions: As O 9�X 9 o Tax OMyc n�P's g �"'P g'e -- �� -- 3 ee9 S C o h/i a r• .C�a.GTim ORE" iC Property Address: Road Name City/Zip .9�y�S►�vc t �G U in a Subdivision provide Information, as follows: Name: /�3o..G T, ire o ,. e fie. T Section: Block: lot: WRITE DIRECTIONS (from Mocicsville) to PROPERTY: z; .a 7~ To 77is ok e .Q1.9 sec. Date Property Flagged:T/3C'1A Got 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 we change, or if the information submitted in this application Is falsified or changed 1, also, understand that I am respo:rslble for all charges Incurred from this appUcadom 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 17- .�"s. a.� c ,tr Go.► s 7'' zpte,, to conduct all testing procedures as necessary to determine the site suitabWty. DATE / /3 0 /,200 / SIGNATURE THIS 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). 4 RevbW DCHD (07/99) L7 Site Revisit Charge Dste(s): Client Notification Date: I EHS: �Q'ygoo Account No. / 5 Invoice No. to v� 00 C.0 __._....._...__..__._..........._219.__....._. _....__._..� r q4w rL , oq p 612 CD r- -�� DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation I APPLICANT INFORMATION Account #: 989900215 Billed To: J. Franck Construction, Inc. Reference Name: Proposed Facility: Residence Property Size: Water Supply: On -Site Well PROPERTY INFORMATION Tax PIN/EH #: 5860-85-3698 Subdivision Info: Baltimore Heights Lot # 1 Location/Address: Montclair Drive -27006 see map Date Evaluated: Community Evaluation By: Auger Boring Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % 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: LONG-TERM ACCEPTANCE RA' REMARKS: EVALUATION BY: OTHER(S) PRESENT: 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 05/99 (Revised)