181 Greenfield Road Lot 40Dav
>.016
Clarksville
37059-801,
CLARKSVILLE
Davie County
DAVIE COUNTY R-20
WILLIAM R. DAME
WILLIAM R DAVIE
NORTH DAVIE
MnB2
DAVIE COUNTY
M.
[all
All data Is provided as Is witlmut warrantyor guarantee of any Idnd eltineretpresxd or Implied Including but not limited to the
Davie County, Implied wamantiee of merchantability or lltnessfor a particularum All user, of Davie Courdy's GISs lto MMall hold harmies,e
Comfy ofDavie, Worth Carolina, fh agenda, conaubaMa, tontratdars"mployeeafromanyand at ddma oruuses of adlon dueto
NC oradamgoalarthenaearinabmtyroaaetheGlsda proemedbythis wemlto
WARNING: THIS IS NOT A SURVEY
Parcel Information__—, _
Parcel Number.
D301OA0040
Township:
NCPIN Number.
5822153119
Municipality:
Account Number:
82529537
I
Census Tract
Listed Owner 1:
KISER LARRY D
Voting Precinct:
Mailing Address 1:
181 GREENFIELD ROAD
Planning Jurisdiction:
City: MOCKSVILLE
Zoning Class:
State:
NC
Zoning Overlay:
Zip Code:
27028-0000
Voluntary Ag. District
Legal Description:
LOT 40 DUTCHMAN HILLS
Fire Response District:
Assessed Acreage:
0.92 Elementary School Zone:
Deed Date:
412008
Middle School Zone:
Deed Book / Page:
007540652
Soil Types:
Plat Book:
0007
Flood Zone:
Plat Page:'
0190
Watershed Overlay:
Building Value:
Outbuilding & Extra
Freatures Value:
Land Value:
Total Market Value:
Total Assessed Value:
>.016
Clarksville
37059-801,
CLARKSVILLE
Davie County
DAVIE COUNTY R-20
WILLIAM R. DAME
WILLIAM R DAVIE
NORTH DAVIE
MnB2
DAVIE COUNTY
M.
[all
All data Is provided as Is witlmut warrantyor guarantee of any Idnd eltineretpresxd or Implied Including but not limited to the
Davie County, Implied wamantiee of merchantability or lltnessfor a particularum All user, of Davie Courdy's GISs lto MMall hold harmies,e
Comfy ofDavie, Worth Carolina, fh agenda, conaubaMa, tontratdars"mployeeafromanyand at ddma oruuses of adlon dueto
NC oradamgoalarthenaearinabmtyroaaetheGlsda proemedbythis wemlto
DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
P. O. Boz 848/210 Hospital Street /
" Mockwille, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002197
Tax PIN/EH #:
5822-15-3119
Billed To: Chris Johnson
Subdivision Info:
Dutchman Hills Lot # 40
Reference Name:
Location/Address:
181 Greenfield -27028
Proposed Facility: Residence
Property Size:
150 x 270
ATC Number. 3755
*
*NOTE** This ImprovementlOperation 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 Ol #People #Bedrooms �'. #Baths
Dishwasher: E2/ Garbage Disposal: ❑ Washing Machine: G!r Basement w/Plumbing: 0 ' Basement/No Plumbing: 0
Commercial Specification: Facility Type #People_ #People/Shift y#�SSeeats Industrial Waste: ❑
Lot Size OIS Type Water Supply rDesign Wastewater Flow (GPD) 1 b Site: New d/ Repair 0
System Specifications: Tank Size IMIC)GAL. Pump Tank GAL. Trench Width 3�0 u Z11 Rock Depth 1Linear Ft.yCOt
1
Other: 3. imo &hl gj 2ftes I l,SfaL - L.Iac-S 1 n.e-. KA10.
Required Site Modifications/Conditions: losing 0,1 C,oJ ICO ICsQ 51oFG 4005TId ow 1 rD L+'1i
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 p.m. on the day of installation.
Telephone # is (336)751-8760.****
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Environmental F ealth Specialist's Signature:
Date: Z2 0�
` I ,
DCHD 05/99 (Revised)
Account #: 990002197
Billed To: Chris Johnson
Reference Name:
ATC Number: 3755
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5822-15-3119
Subdivision Info: Dutchman Hills Lot#40
Location/Address: 181 Greenfield -27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
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 WASTEW EWMUC-TW IS VALID FOR A PERIOD OF FIVE YEARS.
Health Specialist's Signature:
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovementtOperation 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.
. fry
Septic System Installed By:� n q
Environmental Health Specialist's Signature Date: UJ
DCHD 05/99 (Revised)
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.. APPUCATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATCFEW
Davie County Health Department Envlronmenfelf/ee/fbSeWon
p.0. Box 8118/210 Hospital Street7
,ayS I#e- Mock villeS1N87607028
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"""Ii>PORTANV#e THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL N131i REQUIRED
INI'ORMATIOH IS PROVIDED. Refer to the IN!'ORMIITION BULLETIN for instructions.
1. 'Mar to be Killen Content Parson CX A44 u9A
Wails" Address F 7
city/state/KIP 1A MMee Ale, 1`7oab
business Phone
a. Mer on Permit/ASC is DieSersst'than Above
Mailing Address City/state/tip
a. Application Por: IT ite Evaluation ❑ Improvement Parmit/ATC ❑ Both
e. eystan to service: House O Mobile Home ❑ Business ❑ Industry O Other
e. If Residence: / People 1 Bedrooms 1 Bathrooms
D Diahrashav D Garbage Disposal D Mashing Machine O easement/plumbing O Baaernt/Mo Plumbing
6. Is Business/industry/Others apsaity type
I Commodes
I Showers
I urinals
1 People
I Pink&
I water Coolers
It IMODSnVICE: / Seats Estimated Nater Usage (gallons par day)
7. Type of water supply: 8 County/City ❑ Well ❑ Community
e. Do you anticipate additions or eypamlons of the hellity this system Is Intended to serve? ❑ Yes ❑ No
If yea, what type?
" CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
PLAT or SITE PLAN MUST BB SUBMITTED by the client with THIS APPLICATtnN.
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Property Dime=1 l 23
Tax Office PIN: N -1U - 1.95,5' �qo
Property Address: Rad Name %ad/ 4444-11 1A �a
City/Zip 4D iCL We,
,al;7
U In a Subdivisions provide in/formation, as follows:
Name: /LG AG//hJls n f/ ///��J11
Section: Block: Lot: %o
WRITE DIRECTIONS (from MockrAlle) to PROPERTY:
/0/ Nos A T 9', .,e, Ci,
�rrTer�l�i a/>✓ � �
Date Property 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 we change, or If the Information
submitted in this application Is falsified or changed 1, also, understand that 1 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 aI testing procedures as necessary to determine the site suitsbAlty.
DATE 17-n%r!v-16&)
THIS AREA MAY BE USED FOR DRAWING YOUR SITZ PLAN
property lines and dimensions, structures, setbacks; and septic loc.
Revised DCHD (07/99)
following: Existing and proposed
Site Revisit Charge
I Client Notification Date:
EHS•
Account No.
Invoice No.
► DAVIE COUNTY HEALTH DEPARTMENT '
: Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION '
Account #: 989900111 - Tax PIN/EH #: 5822-14-6855.40
Billed To: ; Gray Potts Subdivision Info: Dutchman Hills Lot # 40 '
Reference Name: Gray Potts Location/Address: Eatons Church Road 27028 -
Proposed Facility Residence Property Size: 51 Acres Date Evaluated: �-C7
Water Supply: On -Site Well Community / Public
Evaluation By:
Auger Boring Pit'. ✓ Cut
FACTORS1 2 3 4 5 6 r,
Landscape position L.. L .
Slope% 3
HORIZON I DEPTH _ 1 0 - 1
Texture groupG C
i.'Consistence
Structure . le -
Mineralogy
tMineralo I 1:I
HORIZON II DEPTH 13 - Ro t Lo _ 7
Texture group G t
'Consistence r SS ST r -r
Structure. S k
Mineralogy1
HORIZON IH DEPTH
Texture group -
Consistence N
Structure :. , . Q C(L
Mineralogy: 1 t
HORIZON IV DEPTH ..
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE' �j
i' G 1 �C,444-,
,SITE CLASSIFICATIO N: 'PS '' EVALUATION BY: < J t�F J
LONG-TERM ACCEPTANCE RATE: �'3j OTHERS) 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 - Loam sand SL - Sand loam L
' Y Y -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 Veryfriable FR- Friable FI -Firm VFI - Very firm EFI - Extremely
ry Y 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)
BOARD-
.?NNING
- the owner of the property shown -
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ch located in the County of Davie
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Ilan of subdivision with my free consent, '-
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ing setback lines and dedicate all streets,
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hermore.., cereby dedicate all sanitary - w
1.414 AC. i
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the Countv of --Davie (if applicable):'
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officer of Davie County,
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my original signature, {111
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