Loading...
108 Greenfield Road Lot 13Davie County, NC Tax Parcel Report Monday, December 19, 2016 Q hmalB - - All data b provided as is wlihoutwarrsnty or guarantee of my kind ettherexpressed or implied including but not limited to the Davie County, hnptiedvaartantles of merchantability orDNess fora particular use. All users M Davie Countfs GIS website&hall hold harmless the County of Davie, North Carolina, its agents, ounsuitarde cerMctas or employeeafrom any and a0 claims oreauses of action due to nOg NQS; NC or arising out ofthe use orinabillyto usethe GIS data provided bythls website --` ,` 169 j 121 Parcel Number. 0 164 Clarksville WI 5822148795 Municipality: LLI Account Number: 82520332 157--- Z I— —1 I LLI M 154 CLARKSVILLE Ur 108 GREENFIELD ROAD Planning Jurisdiction:. Davie County City: MOCKSVILLE Zoning Class: + State: NC � 145 t 27028-0000 132_, No Legal Description: t1081 r--105 113; WILLIAM R. DAVIE `GREENFIEL 1.14 Elementary School Zone: WILLIAM R DAVIE ROD CT � t 3/2003 Middle School Zone: NORTH DAVIE Deed Book I Page: 004680650 Soil Types: MnB2,MdE Plat Book: 0007 Flood Zone: 156 + Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding & Extra Q hmalB - - All data b provided as is wlihoutwarrsnty or guarantee of my kind ettherexpressed or implied including but not limited to the Davie County, hnptiedvaartantles of merchantability orDNess fora particular use. All users M Davie Countfs GIS website&hall hold harmless the County of Davie, North Carolina, its agents, ounsuitarde cerMctas or employeeafrom any and a0 claims oreauses of action due to nOg NQS; NC or arising out ofthe use orinabillyto usethe GIS data provided bythls website WARNING: TMS IS NOT A SURVEY Parcel Information Parcel Number. D301OA0013 Township: Clarksville NCPIN Number. 5822148795 Municipality: Account Number: 82520332 Census Tract: 37059-801 Listed Owner 1: BROOKS BRANDON M Voting Precinct: CLARKSVILLE Mailing Address 1: 108 GREENFIELD ROAD Planning Jurisdiction:. Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag. District No Legal Description: LOT 13 DUTCHMAN HILLS Fire Response District: WILLIAM R. DAVIE Assessed Acreage: 1.14 Elementary School Zone: WILLIAM R DAVIE Deed Date: 3/2003 Middle School Zone: NORTH DAVIE Deed Book I Page: 004680650 Soil Types: MnB2,MdE Plat Book: 0007 Flood Zone: Plat Page: 190 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding & Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: Q hmalB - - All data b provided as is wlihoutwarrsnty or guarantee of my kind ettherexpressed or implied including but not limited to the Davie County, hnptiedvaartantles of merchantability orDNess fora particular use. All users M Davie Countfs GIS website&hall hold harmless the County of Davie, North Carolina, its agents, ounsuitarde cerMctas or employeeafrom any and a0 claims oreauses of action due to nOg NQS; NC or arising out ofthe use orinabillyto usethe GIS data provided bythls website � e OPERATION PERMIT , Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 . Applicant: Brandon and Amanda Brooks Property owner. Brandon and Amanda Brooks Address: 108 Greenfield Road Address: 108 Greenfield Road City: Mocksville ;City: Mocksville StatefZip: NC 27028 State0p: NC 27028 .Phone #: - (336) 941-3049 phone #: (336) 941-3049 . Property Location & Site Information Address/Road #: Subdivision: Dutchman Hills Phase: Lot: 13 108 Greenfield Inches Mocksville NC 27028 Directions Structure -SINGLE FAMILY_ - .Hwy', 610 N. to Easton's Ch Road turn right. 1st left ont Highland. At stop sign, turn left House is 1st on # of Bedrooms: 3 right # of People: 'Water Supply: PUBLIC Inches *IP Issued by :_ 'System Classificatan/Description: 4 TYPE II A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140. Nations, Robert Saprolite System? OYes ®No Design Flow: 3 6 0 - * GRAVITY -SERIAL Pump Required? -Distribution Type: Oyes (9)No Soil Application Rate: 0 2 7 5 'Pre -Treatment: Drain field Sq -B - *System Type: INFILTRATOR QUICK4STANDARD CNAMnficationField rain Lines 4 Installer: randy Miller Trench Length: 3 0 4 it. Certification #: 1128 Trench Spacing: - 9 Olnches O.C. + Feet O.C. 'EHS: Trench Width: 3 Inches - 2i Feet 0 8/ 0 6/ 2 0 1 5 . Date: Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover, a 4 Approval Status ' Inches , a Maximum Trench Depth: 3 6®Approved ❑ Disapproved Inches Maximum Soil Cover. D 4 CDP FJIeNumber 138327-1 Manufacturer. Shoat STB: 760 Gallons: 1000 Manufacturer. Date: 0 ;2 7/ 2 0 1 5 'Filter Brand: POLYLOK PL -122 With Pipe Adapter ST Marker. 0 Yes IE No nforced Tank: [] Yes [E No 1 Piece Tank: El Yes [E NO Date: Ac Tank County ID Number:. Let. Long: Installer Randy Miller Certification #: 1128 *EH S: Date: 0 8/ 0 6/ 2 0 1 5 ...... A Approval Status Approved❑ ADisai d Pump Tank Manufacturer. Installer. PT: Certification 9: Gallons: 1EHS: •�Date; Date: RiserSealed ❑ Yes 0 No Riser Height: 0 Yes 13 N0 (Min. 6 in.) :ApprovalStalus Reinforced Tank: [:1 Yes 0 No " 0 Obf6V6d O"Approved" MM isa Tank. �es ❑ �o .1Piece Supply Line Pipe Size: inch diameter Installer. Pipe Length: feet Certification 'Schedule: EHS: Pressure Rated El Yes 0 No i Date; Approved fittings ❑ Yes No Rprove tatu S E] Approved El Disapproved' Pump Requirement Pump Type: Installer: Dosing Volume: Gal Certification 9: Draw Down: Inches *EHS: *Chain: Date. Valves Accessible ❑ Yes El No Flow Adjustment Valve E] Yes 0 No Check -valve El Yes 0 No PVC Unions ❑Yes El No E] Disapproved Vent Hole E] Yes 0 No Anti -siphon Hole 0 Yes El No • CDP Fle Number 138321-1 NEMA4XBoxorEquivalent ❑ Yes ❑ No _Box 12 inches Above Grade ❑ Yes ❑ No Box Adj.To Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No Pump Manually Operable ❑ Yes ❑ NO 'Activation Method: Alarm Audible_ ❑ Yes ❑ No Alarm Visible ❑ Yes ❑ No 2140 - Nations, Robert County ID Number: Installer. Certification #: 'EHS: Date: ,Approve Status ❑ Approve`d❑Disapproved. . *Operation _Permit completed by: Authorized State Agent: Date of Issue: 0 8 0 6 2 0 1 5 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 184-:1900 ef. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE u A sewage septic system. Rule .1961 requires that a Type TYPE II A septic system meet the following criteria: Minimum System Review..ByTheLocal Health Department: N/A Management Entity: OWNER -.Minimum System InspectionNaintenance Frequency By Certified Operator: WA Reporting Frequency By Certified Operator., N/A Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. . Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management enttyprior to the issuance of an Operation Perm it for a system required to be maintained by a public or private management entty, unless the system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and operation, responsibilities of the ownerand systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. I shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ©Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** AM OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 138327-l' County File Number: Date: /./ W W O Inch Scale- OBlock =t R_ OMNI ■■■■■E■ ■■�■■■■■■®■■® ■ ■E■NEE■■■EN■■■E■ ■■ ■■ ■■■■■■■■■■■■M■■■■■■■ ■■ ■■■■■� � NOON■■■ ME ■E■■■� ■■■ ■■ ■■■ MNEME �■■■ ■■ EN - ON NOON ■E■ ■E NONE■ ■■ No No ■■■E■ u -■■®E 0 ■■E on ■■■ ■■ �. _ ■ No ON ®■ No mom M No No ■■ ■■�i■ - ■■■S■ ■■ MINEE m ■■ .■■ ■■mom■ ■■■ ■■ -- ME■vM NOON■ ■ �- No ON ■ ■■E■■■■ MENNE■ ■ ■■■■■� ■ ■EEE■ NOON N■ ■■ essrng* Applicant: Address: City: State/Zip: HEALTH DEPARTMENT RE Davie County Health Department 210 Hospital Street P.O. Box 848 *CDP File Number 138327 - 1- County ID Number: Evaluated For: HDR/WWC Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 PERMITVALID 0 5 / a 8/ a 0 1 9 Brandon and Amanda Brooks 108 Greenfield Road Mocksville NC 27028 Phone #: (336) 941-3049 UNTIL: — -- Property Owner: Brandon and Amanda Brooks Address: 108 Greenfield Road City: Mocksville State/Zip: INC 27028 Phone (336)941-3049 Property Location 8. Site Information Address 108 Greenfield Subdivision: Dutchman Hills Road # Mocksville NC 27028 *Structure: SINGLE FAMILY # of Bedrooms: 3 'Water Supply: PUBLIC Basement: F-1 Yes F-] No *Proposed Improvement: Pool House # of People: Phase: Lot: 13 Township: Directions Hwy 610 N. to Easton's Ch Road turn right. 1st left ont Highland. At stop sign, turn left House is 1st on right Type of Business: Total sq. Footage: No. Of Employees: Pump and crush old septic tank, place new 1000 gallon tank as shown in new drawing, and add septic lines accordingly. No portion of the septic system can be within 15 feet of pool, basement, or 10 feet from any property line. 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? O Yes O No Applicant/Legal Reps. Signature *Date: / / *Issued By: 2140 - Nations, Robert *Date of Issue: 0 5 / a 3 / a 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** `. ® Hand Drawing OlmportDrawing a�mm�r 525 HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Type: Health Department Release r CDP File Number: 138327 - 1 County File Number: Date: 05 /.1 7/2014 O Inch Scale:. OBlock .ft. O N/A reyc 4 vi 4 Q� 5-�4a a�� a �li •-�-�� x eb IroW' ;5� s - _�_C Q ok �c 01 {+ i reyc 4 vi 4 Q� 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 a -M41 CDP File Number: 138327 - 1 County File Number: Date: 05/ 077 /.1014 O y� r d' �OON tii 0 HEALTH DEPARTMENT RE s*.Q,rFp Davie County Health Department 210 Hospital Street P.O. Box 848 @a *• Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Brandon and Amanda Brooks Address: 108 Greenfield Road City: Mocksville State/Zip: NC 27028 Phone #: (336) 941-3049 PERMIT VALID 0 5/.1 8/ 1 0 1 9 UNTIL: -- — Property owner. Brandon and Amanda Brooks Address: 108 Greenfield Road City: Mocksville State/Zip: NC 27028 hone #: (336) 941-3049 Property Location 8 Site Information Address 108 Greenfield Subdivision: Dutchman Hills Phase: Lot• 13 Road# Mocksville NC 27028 — SINGLE FAMILY Township: *Structure: Directions # of Bedrooms: 3 # of People: Hwy 610 N. to Easton's Ch Road tum right. 1st left ont Highland. At stop sign, tum left House is 1st on right -Water Supply: PUBLIC Basement ❑ Yes ❑ No *Proposed Improvement: Pool House Type of Business: Total sq. Footage: No. Of Employees: Pump and crush old septic tank, place new 1000 gallon tank as shown in new drawing, and add septic lines accordingly. No portion of the septic system can be within 15 feet of pool, basement, or 10 feet from any property line. 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 5 / a 7 / a 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** 0 Hand Drawing 0 Import Drawing Chr Re.dW.g 525 Phone: (336) — 753 - 6780 Davie County Health Departmer Environmental Health Section P.O. Box 848 210 Hospital Street Courier # : 09-40-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement ❑ Remodeling ❑ Reconnectim M u c{Zsvi 11-e � . VC 2.702-2 Number336 9 L- U 9 336 *9-6 7y Email Address: Fax: (336)-753-1680 :uS Detailed Directions ToSite: dal Al.+6 Ea4-on`5 ('1 fAr& 1 12d �rn P,±)I St Le-4OV1+0 _ St .bt(khM ills L0�#/3 Property Address: - n i ! Please Fill In The Following Infformation About The EXISTING ,,ING� Facility: ' Name System Installed Under: 1 �� �i�i I • 9L_ aM� _Type Of Facility: (.(,XPi _ Date System Installed (MontlVDate/Year): a003 Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes ❑ No V If Yes, For How Any Known Problems? Yes ❑ MY' If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Number Of Bedrooms: Number of People Pool Size: 12 % 3 Garage Size: Other: ' - Requested By: &nat -Q 9 Date Requested: ri /02 -Lam/ For Environmental Health Office Use Only Approved ❑ Disapproved ❑ Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended, 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: Cash ❑ Check Money Order ❑ # Amount:$ Aaw Date: Paid By: Received By: Account #: 3V7 Invoice #: 8 3 9' nrnuAnn Tvne- HEALTH DEPARTMENT RELEASE Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Haalth nannOmant Ralpacp CDP File Number: 138327 - 1 County File Number: Date: 05 /a7/.1014 O Inch Scale:. O Block -ft. (i N/A O�aw�ibunc�. 6 UOI� { 7� � 1s 36 ` s��►c. i .. sysf paf�o � se t•� � . 17 o Y lyo`^se 30 6o ft .i:'..-6.1 ? DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002128 Tax PIN/EH #: 5822-14-8795 Billed To: Phase IV Realty Subdivision Info: Dutchman Hills Lot # 13 Reference Name: Location/Address: 108 Greenfield -27028 Proposed Facility: Residence Property Size: 1.136 acres ATC Number: 3270 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 witp Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). S AUTHORIZATION FOR WASTEWATVOSTR TION IS VALID F R A PE D vii ARS. Environmental Health Specialist's Signature: _ Da e: 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 -la a-gaara tthat the system will function satisfactorily for any given period of time. En r Septic System Installed By: Environmental Health Specialist's Signature: Date: rerun nvoo rpa.A; a,A DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002128 Billed To: Phase IV Realty Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5822-14-8795 Subdivision Info: Dutchman Hills Lot # 13 Location/Address: 108 Greenfield -27028 Property Size: 1.136 acres ATC Number: 3270 **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 A #People #Bedrooms -,T #Baths �,?_ Dishwasher Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size �/? Type Water Supply Design Wastewater Flow (GPD) ' � e Site: New 0' Repair ❑ System Specifications: Tank Size/—GAL. Pump Tank GAL. Trench Width �C,Rock Depth Linear Ft. �DD Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APpR( FINISHED GRADE. ****NOTICE: Contact a representative of system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to t. m. on E- F NT FIL.TER. RISER(S) IF 6 " BELOW Dayie Coun Health Department for final inspection of this dayof�ikstallAtion. Telephone # is (336)751-8760.**** Pe- J Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) Account #: 990002128 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Billed To: Phase IV Realty Reference Name: Proposed Facility: Residence Tax PIN/EH #: 5822-14-8795 f°/i( j 0 Subdivision Info: Dutchman Hills Lot # 13 Location/Address: 108 Greenfield -27028 Property Size: 1.136 acres ATC Number: 3270 **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 E41ENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRAC OR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type #People #Bedrooms C_2_ #Baths .� Dishwasher Garbage Disposal: ❑ Washing Machine Basement w/Plumbing;,e Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply On Design Wastewater Flow (GPDy. d Site: NewZ Repair ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Widths `Rock Depth Linear Ft. ge0 aC� Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 - BELOW FINISHEDGRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this pstim 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 (336)751-8760.**** llun,.,6iZ� ;n �psepr�j� A"O— -�&— , ;> Environmental Health Specialist's Signature: Date: DCHD 05199 (Revised) r � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. ' P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002128 Tax PIN/EH #: 5822-14-8795 Billed To: Phase IV Realty Subdivision Info: Dutchman Hills Lot # 13 Reference Name: Location/Address: 108 Greenfield -27028 Proposed Facility: Residence Property Size: 1.136 acres ATC Number: 3270 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, Sectio .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CU CION IS VALID FOjt ERIOD OF FIVE YEARS. 7,� Environmental Health Specialist's Signature: vJ�j( Date: y , 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: r �.•APS :LOT IS 1 I LOT 11 J _.A ; e... aG -•.. O K3� L07 1i ♦ .[ yr L07 Ia Y I t� - 1 LOT tai S_I Idai �' 1 tCd LOT IS 1 �.. LOT 16 I - I - LOT 04f al w7 to X a S Y I LOT /a0 R I LOT 19 _ e LOT LOT N9 �I a4J1 'C )nr LOT 110 f. j ...ri. [ al arm J1m ::cs 51 LOT 138 a3PK )L as I ' ^f 1 LOT Iil I i -' 9 LOT 113 L07 Ila _ LOT Ivy - 41Y LOT 137 l Ilz i aW � aMJ K I I I LOT 736 RO : -ry a 027 LOT 027 ? : SL -- -- LOT 128 wLOT FL 035 _ wT 128 ` ` I O tp1.q a1Q C coT +zs : •. IZZ I •�., .I 8-1 LOT 134Ell 3'.. Jar.r ( .. [ eue 129 _«Jr .� LOT - r I wT 114 82 LOT I19 i• LM • I - . r.�.. n. 8 \ � ,µr.. i nJpmc � :ur.rr \ LOT I39 LOT 130 1- w.-+ "� I �....�". c..w � ' 2 -'8 LOT 123t LOT 120 f� _ ._ I. V 1- LOT 132 LOT 131 I lu t aa:J K LOT 121wT 11i c t [SFO'.. �[. Mlrm� I .• T[)'• °two /��N'TiF� M■ Tfl-i"'FN Of - - -I- --7 . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Health Department En virianmerif al Health Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL !HE REQUIRED 3 INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN fo1m instructions. 4,2 1. Name to be Billed I I Contact Darton Hailing Address '74 15Ali/G/ '7 B Soma Phone City/state/ZIP lv,s, Al �_ �Q,J Business Phone 2. Name on Permit/ATC if Different than Mailing Address City/State/Zip 3. Application For: 11 Site Evaluation ❑ Improvement Permit/ATC RI/Both 4. System to Service: B House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Reaidence: # People # Bedrooms # Bathrooms CT Dishsashsr W�Garbags Disposal L'i Washing Machine 14-gassmsnt/Plumbing 11 Basement/No plumbing 6. If Business/Industry/Other: specify type # People # Sinks # Commodes # Shonars # Urinals # Mater Coolers IF FOODSEPVICE: # Seats Estimated Water Usage (gallons per day) 7. Type o4 nater supply: 1-1"County/City ❑ Well ❑ Community a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U -No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE T HE REQUIRED PROPER:[ -V INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: A 136 /k WRITE DIRECTIONS (from MockrAlle) to PROPERTY: Tax OlficePIN: # .5�a�o�"�Y�%`/� ��� P,,AV �',,Ky [�/�`- Property Address: Road N m`eC eeX6�.Z 24"Aly"I"OnA/ /b`t,(„CS City/Zip �%Do%9 If in a Subdivision provide information, as foHows: Name: ¢�,'l�� til /]1! ,it L Section: / Block: Lot: / ,: Date Property Flagged: % L' 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 1, also, understand that I am responsible for all charges incurred from this application. 1, hereby, give consent to the Authorized Representative of the Davie Coynty Health Department to enter upon above described property located In Davie County and owned byi� Og �l- tC Jaz u?T r to conduct tt]all testing procedures as necessary to determine the site saftshility. DATE 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). i Revised DCH10 (07/99) Site Revisit Charge Client NolifIcAtIon Date: EHS: Account No. Invoice No.// APPLICATION FOR SIDE EVALtIAIION/ IMPROVEMENT PERMIT & AIC D IE G I j� Davie County Health Department Env/runmental Health Section Ae4 SCS A a P.O. Box 848/210 Hospital Street lyS n Gs/ l /;�C Mock(336)751-B760 HC 27028 P , / d 7 (336)751-8760 lj ***IMPORTANT*** INFORMATION IS THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL PROVIDED.Refers to the INFORMATION BULLETIN for THE REQUIRED instructions. 1. Hama to be billed ,`7� (� y' i -L/ /y /Eiji Contact Parson /]�Y4, IIB �c7 Nailing Address Z% U�U CI✓fff�`-S� Moes Phone city/state/zIP_ e Ale, Mucinase Phone 2. Hama on Porslt/ATC if Different than Above Mailing Address City/state/sip 3. Application For: 19 Bite Evaluation ❑ Improvement Permit/ATC ❑ Both *. BY -ton to sorvios, yr Rouse ❑ Mobile Nome ❑ Business 11 Industry ❑ Other s. If Residence: i People s Bedrooms s Bathrooms ❑ Dishwasher ❑ Garbage Disposal ❑ washing Machine ❑ Beaseont/Pluabing LI Basomant/Mo Plumbing 6. If Business/Industry/Othari Bpaoify typo 0 People / Sink• / Commodes D Showers f Urinals # Mater coolers IF FOODSERVICE: )! Seats Estimated Yater Usage 19allon. par day) I. Type of water supply: 8 County/City ❑ Well ❑ Community B. Do you anticipate additions or expansions of The facility this system Is Intended to serve? ❑ Yes Il No If yes, what type? `**IA/PORT,INT*** CLIENTS AIUSTa MPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLANS MUST BESUBMITTED by the client with THIS APPLICATION. Property Dlmensla�7 R�'T' l 1 '� / .3 / -its 5 ('Zo WRITE DIRECTIONS (from Moclavllle) to PROPERTY: Tax Office PIN: it s O - )U - to K.5 -5 - Property Address: Road Name �el }%9 YflN �A City/Zip h'/p�gy� ,�P,�?7/t�y If in a Subdivision provide Information, as follows: Name:/ lo/ A/o,'L T Z,e ioti A Section: Block: Lot: /-Y Date Property Flagged: This Is to certify that the Information provided is correct to the best of my knowledge. 1 understand that any permit(s) Issued hereafter are subject to suspension or revocation, If the site plans or Intended ase change, or If the Information submitted In this application Is falsified or changed 1, also, understand that I am responsible for all charges Incurred from this application. 1, 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 sultsf,111ty. DATE SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Incl a all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Client Notification Dale: EIIS: `� /� v � / � v J Account No. /// Revised DCHD (07/99) % 4 I I Invoice No. LJ _ '413 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 989900111 Tax PIN/EH #: 5822-14-6855.13 Billed To: Gray Potts Subdivision Info: Dutchman Hills Lot # 13 Reference Name: Gray Potts Location/Address: Eatons Church Road -27028 Proposed Facility: Residence Property Size: 51 Acres Date Evaluated: Mineralogy HORIZON II DEPTH 3 / Water Supply: On -Site Well Community Public Structure Evaluation By: Auger Boring Pit Cut HORIZON III DEPTH FACTORS 1 2 3 1 4 5 6 1 i Landscape position Slope % V %_ HORIZON I DEPTH C Texture group C_ Consistence Structure Mineralogy HORIZON II DEPTH 3 Texture group C k Consistence Cr P Structure MineralogyI HORIZON III DEPTH 31 50 Texture group Consistence SS Structure G CL MineralogyI;1 HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: PS EVALUATION BY: �YA1' �VNt)C t-Fa—r LONG-TERM ACCEPTANCE RATE: D 3� REMARKS: 'PS Int {O �JDD w LEGEND OTHER(S) PRESENT: 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 Textur 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 OR - 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 chrome 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD 05/99 (Revised) F.< `DAVIE COUNTY HEALTH DEPARTMENT- OR I Environmental Health Section , 'lip LOT fJ Soil/Site Evaluation to APPLICANT'S NAME / V S DATE EVALUATED PROPOSED FACILITY PROPERTY SIZE 3�yaA/ SUBDIVISION ROAD ,. NAME Water Supply: On-Site Well Community Public Evaluation By: Auge;BoringPit Cut FACTORS1 2 3 4 5 : 6 7 Landscape position Slope% HORIZON I DEPTH i Texture group Consistence Structure Mineralogy HORIZON H DEPTH Texture group . . C. G -Consistence : Structure Mineralogy HORIZON HI DEPTH Texture group Consistence Structure Mineradogy HORIZON IV DEPTH Texture group - Consistence t Structure . Mineralogy SOIL WETNESS . RESTRICTIVE HORIZON ; SAPROLITE CLASSIFICATION 7 :.LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION EVALUATION BY: LONG-TERM ACCEPTANCE RATE: (S)PRESENT: REMARKS:" c , LEGEND { Landscape Position • R-Ridge, . S-Shoulder L-Linear slopeFS-Foot slope N=Nose slope CC-Concave slope CV-Convex slope T-Terrace F,P-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 VFR-Very friable FR-Friable FI-Firm VFI Very firm EFI-Extremely firm - Wet 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 DCan(01-90), _ -