248 Essex Farm Road Lot 23Davie County, NC Tax Parcel Report Tuesday, December 20, 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 / Page
Plat Book:
Plat Page:
Building Value:
Land Value:
Total Assessed Value:
WARNING: THIS IS NOTA SURVEY
Fire Response District:
Parcel Information
: 0.95
F8030A0023 Township:
Shady Grove
5870654147 Municipality:
Middle School Zone:
82529287 Census Tract:
37059-803
BUTLER TERRY BLAKE Voting Precinct:
EAST SHADY GROVE
P O BOX 326 Planning Jurisdiction:
Davie County
ADVANCE Zoning Class:
DAVIE COUNTY R -A
NC Zoning Overlay:
DAVIE COUNTY
27006-0000 Voluntary Ag. District:
No
LOT 23 ESSEX FARM PHASE 1
Fire Response District:
ADVANCE
: 0.95
Elementary School Zone:
SHADY GROVE
6/2008
Middle School Zone:
WILLIAM ELLIS
007610233
Soil Types:
GnB2,GaD
0009
Flood Zone:
290
Watershed Overlay:
DAVIE COUNTY
Outbuilding & Extra
Freatures Value:
Total Market Value:
E01
All data is provided as Is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to thewarrantiesMDavie County, implied wanties of merchantability orness 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 of employees from any and all claims or causes of action due to
j�C' ` or arising out of the use or inability to use the GIS data provided by this website.
Account #: 990005022
Billed To: Terry Butter
Reference Name:
Proposed Facility: Residence
ATC Number: 4871
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
OPERATION PE"&j PIN/EH #: 5870-65-4147.23
Subdivision Info: Essex Farm Lot # 23
Location/Address: 248 Essex Farm Rd -27006
Property Size: .8665 Acres
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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.
!,, 08 f
System Type:_ S.T. Manufacturerr 6 Tank Date 1 Tank Siz
Pump Tank Size e
"Avow
S stem Installed By:_ �-e E.H. Specialist: Dater
_
Y
v r
n(7 11/n6 (Reviged)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005022
Billed To: Terry Butler
Reference Name:
Proposed Facility: Residence
ATC Number: 4871
Tax PIN/EH #: 5870-65-4147.23
Subdivision Info: Essex Farm Lot # 23
Location/Address: 248 Essex Farm Rd -27006
Property Size:8�665Acres
Site Type: 21� ew ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms LA # Bathrooms _ # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size &4, `� Type of Water Supply: tr6ounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) 1,60 Tank Size GAL. Pump Tank GAL.
Trench Width X Max. Trench DepthO-S��1Ro kepth� Linear Ft._
cgdSnstems may also be us
e
Site Modifications/Conditions/Other: y
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
J I OL \� i` o vt
U;G1Q�r�►-�,
P �
Environmental Health Specialist �"'J�'' 'i!i/%� Dater
DCHD 11/06 (Revised)
a
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION gRQP_ER''�' INFORMATION
Account : Tax PIN/EH #: 587tFb�'116 .L
Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # }-3
Reference Name: Brad Coe Location/Address: Cornatzer Rd -27006
Proposed Facility: Residence Property Size: 0.689 ac. Date Evaluated:
Water Supply: • On -Site Well Community
Evaluation By: Auger Boring Pit
Public t/
Cut
FACTORS
y 1
q2 43 4 5 6 7
Landscape position
L
L
Slope %
3
HORIZON I DEPTH
p _ %
Texture groupG
C c
Consistence
Structure
x Al
Mineralogy
P -1
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
x W.LI
LONG-TERM ACCEPTANCE RATE
(3 , :2 o • a-
l�r�
SITE CLASSIFICATION::
LONG-TERM ACCEPTANCE RATE: 0
REMARKS:
LEGEND
EVALUATION BY: Pd.tea f10 h S
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
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
NS - Non sticky SS - Slightly sticky S - Sticky . VS -Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
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
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)
TAR - Long-term acceptance rate - gal/day/ft2 , DCHD 05/05 (Revisech
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
Account #: 990004425 IMPROVEMENT PERTq*IPIN/EH M 5870-64-2265. 1.3
Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # X3
Address: PO Box 340 Location/Address: Cornatzer Rd -27006
City: Mocksville Property Size: U1,1 acre
Reference Name: Brad Coe
Proposed Facility: Residence
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to
revocation if site plans, plat or the intended use change.
Permit Type: ew ❑Repair. ❑Expansion Permit Valid for: 1211 Years ❑No Expiration
Residential Specifications: # Bedrooms 4 # Bathrooms # People Basement❑ Basement plumbing❑
'To'
Design Flow(GPD):
Site Modifications/F
� 55'
CkCdt
Site Plan
Facility Type # People # Seats_
Square Footage(or Dimensions of Facility)
Type of Water Supply: 9'Csounty/City ❑Well ❑Community Well
Conditions: AG stated in 15A NCAC 18A.1969(5�
steed S,otems may == sa �s6
�l
I,
n� �o � t
Environmental Health Specialist
CC e
fl1
LTAR
.a5
Date (0'lG-67
Essex Farm Lot 23
Project No. 4-1773
layout for a 4 bedroom home
Jan -08
FLAG
FLAGGED
LINE #
COLOR BS
HI
FS
ELEVATION
LINE LENGTH
TBM
2.2
100.0
INSTR.1
102.2
Repair
1
Pink
2.50
99.7
40
2
Red
2.90
99.3
60
3
Orange
3.80
98.4
65
4
Yellow
4.20
98.0
52
5
Blue
5.00
97.2
46
6
Pink
5.50
96.7
38
Total
301
System
7
Blue
4.20
98.0
30
8
Pink
4.90
97.3
51
9
Red
5.40
96.8
55
10
Orange
5.90
96.3.
56
11
Yellow
6.70
95.5
42
12
Blue
7.80
94.4
30
13
Pink
8.60
93.6
.27
Total
291
LINE LTAR SYSTEM INNOVATIVE
LENGTH GPD/F12 TYPE TYPE DISTRIBUTION
*System 301 0.275 Panel 50% LPP
Repair 291 0.275 Panel 50% LPP
Notes:
**TBM is assumed to be 100'
**All measures in feet
**Nitrification lines are demonstrated on contour via colored pin flags
**BS and FS indicate rod readings
PPBPS DESIGN SPECIFICATIONS
#Holes
Line
Line
Line
Line #
Color
#Panels
Panel
Length
Hole Size
Head
Flow
7
Blue
7
1
30
5/32"
2.0
3.69
8
Pink
11
1
51
5/32"
2.0
5.33
9
Red
12
1
55
5/32"
2.0
6.15
10
Orange
13
1
56
5/32"
2.0
4.92
11
Yellow
9
1
42
5/32"
2.0
4.10
12
Blue
6
1
30
5/32"
2.0
3.28
13
Pink
6
1
27
5/32"
2.0
3.28
Total
64
291
30.75
PPBPS DESIGN SPECIFICATIONS (REPAIR)
#Holes
Line
Line
Line
Line #
Color
#Panels
Panel
Length
Hole Size
Head
Flow
1
Pink
9
1
40
5/32"
2.0
3.69
2
Red
13
1
60
5/32"
2.0
5.33
3
Orange
15
1
65
5/32"
2.0
6.15
4
Yellow
12
1
52
5/32"
2.0
4.92
5
Blue
10
1
46
5/32"
2.0
4.10
6
Pink
8
1
38
5/32"
2.0
3.28
Total
67
301
27.47
GRAPHIC SCALE
1t7 = 407
FUTURE EASEMENT
10" LDP SYSTEM
0 60'
DROP BOXES 768 LF
--
Yellow 17.4 75
Orange 15.3 80'
J!d 12.6 93�
---- Blue 10.3 88'
._ _ _.... _. _..... Yellow
6.5 g4'
Orange _ 4,3 98'
Blue 2.5 100'
1500 gal Red 7.2 43'
tank
6.4 40' PPBPS REPAIR
Y6110, 6.0 3s,
4 BR Orange 5.4 30'
Red 4.3 33'
Pink 3.3 28.
B/U° 28 25.
01,19
* J0.
Rea, 0.9 36•
E ^ E A ^ T
i SHEET TRI,E: PRQIECT NAME: > G O> y C J E
C i
4 BEDROOM SEPTIC SYSTEM LAYOUT - SOT 23 ESSEX FARM - SVC.
�nC / c
Soil & Environmental Consultants, PA
SKETCH MAP DANE COUNTY, N—H CAROLINA1 IM IWPDip Ck • C—rd. Wdh C-Im 20M! - ft— (700770-0405 • F- (704) 720-9406 A 0
MA12— �/
Reference Name:
Proposed Facility: Residence
**NOTE* *This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to
revocation if site plans, plat or the intended use change.
Permit Type: Clew ❑Repair ❑Expansion Permit Valid for: [1"5 Years ❑No Expiration
Residential Specifications: # Bedrooms # Bathrooms. # People BasementC7 Basement plumbinggl"�-
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): °' Type of Water Supply: Otounty/City ❑Well ❑CommunityWell
At stated in 15A NCAC 18A.1969(6
Site Modifications/Permit Conditions: accepted Systems mny also be < n
System Type LTAR
Initial Lo P G. e• a 7
Rt-nnir 'Do -P, 5 G'. ]7< -
Site Planj X
r GS
i _ Cu
01
Environmental Health Specialist
i.p.11-06
Date &
l
Davie County Environmental Health
'
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
IMPROVEMENT PERMIT
Account M
990005022
Tax PIN/EH M
5870-65-4147.23
Billed To:
Terry Butler
Subdivision Info:
Essex Farm Lot # 23
Address:
PO Box 326
Location/Address:
248 Essex Farm Rd -27006
City:
Advance
Property Size:
.8665 Acres
Reference Name:
Proposed Facility: Residence
**NOTE* *This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to
revocation if site plans, plat or the intended use change.
Permit Type: Clew ❑Repair ❑Expansion Permit Valid for: [1"5 Years ❑No Expiration
Residential Specifications: # Bedrooms # Bathrooms. # People BasementC7 Basement plumbinggl"�-
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): °' Type of Water Supply: Otounty/City ❑Well ❑CommunityWell
At stated in 15A NCAC 18A.1969(6
Site Modifications/Permit Conditions: accepted Systems mny also be < n
System Type LTAR
Initial Lo P G. e• a 7
Rt-nnir 'Do -P, 5 G'. ]7< -
Site Planj X
r GS
i _ Cu
01
Environmental Health Specialist
i.p.11-06
Date &
MARK BOUNDARY
&Greg 223
e�w 20.E 5Y
PM�c 79-o
~Y.n� 17.4 76'
c,aw• fas ad.-
EW
d.-
E EMwllon \\ -4Y
CREATE 20' EASEMENT
LDP SYSTEM
REMOVE EASEMENT
MARK BOUNDARY
Y.ao, ao W.
- Orunqo 5.4 30'
—Rod,-4.3 3Y
_. Pink_ 3.3 28'
_A -2&-W
Ydlow 2.1 26' -
PANEL SYSTEM
❑ ❑ NM cm
ow oP
DEPARTMENT OF EPVVIRONMENT AND NATURAL RESOURCES
DMSION OF ENVIRONMENTAL HEALTH
ON-STfE WASTEWATER SEC'T'ION
SOIL/SITE EVALUATION
for ON-SITE WASTEWATER SYSTEM
Sheet_ of
PROPERTY ID #:
COUNTY: —Davie
OWNER: _ Michael Hauser Construction
APPLICATION DATE 1/08/2008
ADDRESS: DATE EVALUATED:
PROPOSED FACILITY:11 BR Home PROPOSED DESIGN FLOW (.1949): _360 yea PROPERTY SIZE:
LOCATION OF SITE: Lot 10� zZ PROPERTY RECORDED: _
WATER SUPPLY: Private tc $ Well, Spring Other
EVALUATION METHOD: Auger Boring :. Pit Cut TYPE OF WASTEWATER: - Sewage Industrial Process
Mixed
P
R
F
I
L
E
#
.1940
LANDSCAPE
POSITION/
SLOPE % :
HORIZON
DEPTH
(IN-)
SOIL MORPHOLOGY
(:1941j
OTHER
PROFILE FACTORS
PROFILE
CLASS
& LTAR
.1941
STRUCTURFJ
TEXTURE
.1941
CONSISTENCE/
MINERALOGY
.1942.
SOIL
WETNESSt
COLOR
.1943
SOIL
DEPTH
.1956
SAPRO
CLASS
.1944
RESTR
HORIZ
5
5-8%
L
0-3
W,F.GR/SCL
NS,NP,FR/NEXP
28"
28"
NA
PS
PS (L ff)
3-12
M F.SBK/C
SS,SP,FUSEXP
12-28
M,M,SBK/C
SS,SP,FR/SEXP
6
5-8%
L
0.10
W,P.GR/SL
NS,NP,FR/NEXP
17"
17"
NA
PS
NS vA
10-17
M,M,SBK/CL
SS,SP.FR/SEXP
7
L
5-8%
0-6
W,F.GR/CL
NS,NPXR/NEXP
25"
25"
NA
PS
PS (L PF)
2
6-17
M,M,SBK/L
SS,SP,FR/SEXP
17-27
M:M,SBK/CL
SS,SP,MEXP
8
L
15-18%
0.12
W,F.GR/CL
NS,NP,FR/NEXP
30"
30"
NA
PS
Sall
`NEN DEL
PS
12-37
M,M,SBK/C
SS,SP,FR/SEXP
37+
W,F,SBK/CL
SS,SPXWSEXP
DESCRIPTION
INrr AL SYSTEM
REPAIR SYSTEM
OTHER FACTORS (.1946): '' x •'
SITE CLASSIFICATION (,1948 i'h • " '� "'E "�+'�'
Available Space (.1945)
/.A11Qu7'
EVALUATED BY: . D t!' '
•'"""�'
1, p j'
System Type(s)
OTHER(S)PRESENT: WO
F N
Site LTAR
.Z S .
SOIL/SITE EVALUATION
(Continuation Sheet)
DEPARTMENT OF ENVIRONMENT
AND NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL HEALTH
PROPERTY ID #:
DATE OF EVALUATION:
COUNTY:
Sheet_ of_
P
R
F
1
L
E
#
.1940
LANDSCAP.
E
POSITION/
SLOPE %
HORIZ
ON.
DEPTH
DEPT
SOIL MORPHOLOGY
(.1941)
OTHER
PROFILE FACTORS
PROFILE
CLASS
& LTAR
-1941
STRUCTURE/.
TEXTURE
.1941
CONSISTENCE/
MINERALOGY
.1942
SOIL
WETNESS/
COLOR
1943
SOIL
DEPTH
' '
.1956'
SAPRO
CLASS
.1944
RESTR
HORIZ
9
L
5-8%
0.17
W,F.GR/SL
NS,NP,FR/NEXP
>37'
>37"
NA
PS
PS
r
17)
17.31
M,M,SBK/CL
SS,SP,FR/SEXP
31-37+
M,M,SBK/C
SS,SP,FR/SE(P
O
15-18%
0-7
W,F.GR/SCL
NS NP,FR/NEXP
40"
40"
NA
PS
PS
tis
7-20
M,M,GR/CL
SS,SP,FR/SEXP
2040
M,M,SBK/C
SS,SP,FR/SEXP
40-46+
M,F,SBK/C
SS,SP,FR/SEXP
1
24-27%
0.3
W,F.GR/SCL
NS,NP,FR/NEXP
>45"
42"
PS
PS
PS
•Z'�
3-28
M,M,SBK/C
SS,SP,FR/SEXP
2812
W,M,SBK/CL
SS,SP,FR/SEXP ,
42-45+
S/MASSIVFJL
SS,SP,FR/SEXP
1
2
24-27%
0-13
W,F.GR/SCL
NS NP,FR/NEXP
>42"
>42"
NA
PS
PS
.3
13-34
M,M,SBK/C
SS,SP,FR/SEXP
34-42+
W M,SBK/CL
SS,SP,FR/SEXP
1
1
3
24-27%
0-5
W F.GR/SCL
NS NP,FR/NEXP
>47"
36"
G
PS
D Solt
�E4C-Y
PS
PS
2'
5-25
M,M,SBK/C
SS,SP,FUSEXP
23-36
W,F,SBK/CL
SS,SP,FR/SEXP
36-47
S/MASSIVE/CL
SS,SP,FR/SEXP
Essex Farm Lot 23
Project No. 4-1773
layout for a 4 bedroom home
May -08
FLAG
FLAGGED
LINE #
COLOR BS
HI
FS
ELEVATION LINE LENGTH
TBM
2.8
100.0
INSTR.1
102.8
Repair
1
Red
0.90
101.9
36
2
Orange
1.40
101.4
30
3
Blue
2.80
100.0
24
4
Pink
3.30
99.5
29
5
Red
4.30
98.5
36
6
Orange
5.40
97.4
30
7
Yellow
6.00
96.8
38
8
Blue
6.40
96.4
44
9
Pink
6.90
95.9
44
10
Red
7.20
95.6
50
Total
361
System
11
Blue 9.00
2.50
90.6
100
12
Orange
4.30
88.8
98
13
Yellow 6.5
0.80
86.6
94
14
Pink
2.70
84.7
90
15
Blue
4.60
82.8
88
16
Red
6.90
80.5
83
17
Orange
9.60
77.8
80
18
Yellow 11.7
0.70
75.7
75
19
Pink
2.30
74.1
60
Total
768
LINE LTAR
SYSTEM
INNOVATIVE
TRENCH
LENGTH GPD/FT'
TYPE
TYPE
DISTRIBUTIOP
BOTTOM
* System
768 0.25
LDP
n/a
Gravity
24"
Repair
361 0.275
Panel
50%
UP
30"
Notes:
**TBM is assumed to be 100'
**All measures in feet
**Nitrification lines are demonstrated
on contour via colored pin flags
**BS and FS indicate rod readings
Line #
1
2
3
4
5
6
7
8
9
10
PPBPS DESIGN SPECIFICATIONS (REPAIR)
#Holes
Line
Line
Line
Color
#Panels
Panel
Length
Hole Size
Head
Flow
Red
8
1
36
5/32"
2.0
3.28
Orange
7
1
30
5/32"
2.0
2.87
Blue
5
1
24
5/32"
2.0
2.05
Pink
6
1
29
5/32"
2.0
2.46
Red
8
1
36
5/32"
2.0
3.28
Orange
7
1
30
5/32"
2.0
2.87
Yellow
8
1
38
5/32"
2.0
3.28
Blue
10
1
44
5/32"
2.0
4.10
Pink
10
1
44
5/32"
2.0
4.10
Red
11
1
50
5/32"
2.0
4.51
Total
80
361
32.80
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O. Box 848/210 Hospital Street
Courier 409-40-06
Mocksville, NC 27028
Phone#: (336) 751-8760
Fax#: (336) 751-8786
Notice of Intent to SUSPEND/REVOKE Improvement
Permit or Construction Authorization
May 20, 2008
Terry Blake Butler
P.O. Box 326
Advance, NC 27006
RE: Notice of Intent to Revoke/Suspend Improvement Permit/Construction
Authorization
Dear Mr. Butler:
The Davie County Environmental Health Department inspected the site for the onsite
wastewater system located at Essex Farm Subdivision Lot 23 for compliance with the
Laws (Article 11 of Chapter 130A of the North Carolina General Statutes), Rules (15A
NCAC 18A. 1900 et seq.), and Improvement Permit/Construction Authorization 4700
conditions. As a result of this inspection, the Department has determined the following
violations:
1. 15A NCAC 18A.194.5
This is to notify you that based on these violations, the Department intends to
revoke your Construction Authorization #4824, 30 days from the date of this notice.
If the health department determines that all of the violations have been corrected before
thirty (30) days expire, the revocation will not go into effect. If the permit is revoked, you
must apply for a new Construction Authorization and meet the current laws and rules
necessary to obtain a new permit.
You have a right to an informal review of this decision. You may request an informal
review by the environmental health supervisor at the local health department. You may
also request an informal review by the N. C. Department of Environment and Natural
Resources regional specialist. A request for informal review must be made in writing to
the local health department.
You have the right to a formal appeal of this decision by filing a petition for a contested
case hearing with the Office of Administrative Hearings, 6714 Mail Service Center,
Raleigh, NC, 27699-6714. To obtain a petition form (H-06), you may write the Office of
Administrative Hearings, call that office at 919.733.0926, or from their web site at
www.oah.state.nc.us/hearings. The petition for a contested case hearing must be filed in
accordance with the provisions of North Carolina General Statutes 130A-24, 15013-23,
and all other applicable provisions of Chapter 150B. N. C. General Statute 130A-335 (g)
provides that your hearing would be held in the county where your property is located.
If you wish to pursue a formal appeal, you must file the petition form with the Office of
Administrative Hearings WITHIN 30 DAYS OF THE DATE OF THIS NOTICE.
Meeting the 30 day deadline is critical to your right to a formal appeal. Beginning a
formal appeal within 30 days will not interfere with any informal review that you may
request.
If you file a petition for a contested case with the Office of Administrative Hearings, you
are required by law (NCGS 150B-23) to send a copy of your petition to the North
Carolina Department of Environment and Natural Resources. Send the copy to: Office of
General Counsel, NC Department of Environment and Natural Resources, 1601 Mail
Service Center, Raleigh, NC 27699-1601. Sending a petition or a copy of the petition to
the local health department will NOT satisfy the filing requirements of the NC General
Statutes.
You may call or write the local health department if you need additional information or
assistance.
Sincerely,
Robert M. Nations, RS
Environmental Health Specialist
Cc: Joe Mando, Environmental Health Supervisor
. f '
GRAPHIC SCALE
1"=400
plT 10
O
DROP BOXES
FUTURE EASEMENT
O IT 8
PIT 9 P
10" LDP SYSTEM
768 LF
YIIOw 17.4 75'
Orange 15.3
(6110wj.5 94!
Oran
Blue 2.5 100'
1'IT
15001 gal Red 7.2 43' 13
tank
\ Pik
k B9
3g•
Blue 6.4 40'
Yellow 6.0 35.
Orange 5.4 30'
4 BR
_ Red 4.3 33'
Pink .3.3.28'
JO.
0.8,
PPBPS REPAIR
Z SHEET TITLE: PROJECT NAPE:
S&
' O O 5 p 2 2 E
4 BEDROOM SEPTIC SYSTEM IAYOUT - LOT 23 ESSEX FARM - S I.JC.
Soil & Environmental Consultants, PA A
SKETCH MAP DAMECWNIY, NORTH CAROLINA1 jb {/^Ift CI R a0n0 4 N01N C=bm "M * ft I C?04) -*M R Fi CM) M -"W � C� C
YAY ]OOE v
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S 84'-58'-52" E
10.07'
THIS LINE REPRESENTS THE `
CENTER OF A PROPOSED 20'
ULITITY (SEPTIC PUMP)
EASEMENT FOR USE BY /'��
22 AS ACCESS TO AREAO
N THE FUTURE PHASE
OF ESSEX FARM LOT 22
ONNW.
h�
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note: existing area for
septic easment to be
removed (existing easement area
Is the portion of lot 23 which lies
north of this line)
ESSEX
FARM ROAD 175.34'
N 82'-28'-0
LOT 24
Curve Radius Chord Bearing and Distance
C1 50.00' N 27'-34-55" W 47.66'
W
I
Arc Length
49.68'
ESSEX FARM
(FUTURE PHASE)
82'-28'-00" W
10.13'
VICINITY (no scale)
60 30
0 60
MAP FOR
T.
Blake Butler
(2)
WATER METER
R/W RIGHT—OF—WAY
SCALE
COUNTY TOWNSHIP DATE
PREC. RATIO
®
SEWER MANHOLE
—.— RUNNING WATER
1" = 60
Davie Shady Grove 7 June 2006
1:10,000 +
•
IRON FOUND
—E --E— OVERHEAD POWER LINE
PROPERTY DESC
roh. DB 746 PG 124 —Terry Blake and Amber Lynn Butler
O
a
" SET
MONUMENT
O POWER POLE
Lot 23 `Essex Form Phase 1, pne two PB 9 PG 290
PROPERTY LINE
(surveyed)
MY SEAL AND SIGNATURE
JOB #
— — —
— PROPERTY LINE
CERTIFY THAT THIS MAP IS
COE FORESTRY & SURVEYING
06107
(not surveyed)
THE RESULT OF AN ACTUAL
P.O. BOX 36
SURVEY PERFORMED UNDER
DRAFTED BY:
WALLBURG, N.C. 27373
SURVEYED BY
® POINT NOT MONUMENTED
MY SUPERVISION.
DBC
PHONE/FAX (336) 769-4673
DBC/CLJ
V S
I OR ` EVALUATION/IMPROVEMENT PERMIT & ATC
v e County Environmental Health
P. . Box 848/210 Hospital Street
Mocksville, NC 27028
)751-8760/ Fax (336)751-8786
�
Application or: i7. Sit uation/Improvement Permit el uthorization To Construct(ATC) ❑ Both
Type of App ' ' n: ❑New System ❑Repair to Existing System ❑Expansion/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 to be Billed ! G Rul/er Contact Person A4 -ad Atuiled,
Billing Address .0 . 13QX 07-f, Home Phone
City/State/ZIP IV(i 7-100/1Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
r1cVr ltll Y 11NrUK1ViAJL1U1N
'Date House/Paciltty Corners Flaued & -7-01
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 mon �hs wi site plan, no expiration with complete plat.)
Owner's Name S'fl Ma PSC ✓eCN- Phone Number
Owner's Address City/State/Zip
Property Address 1-49' 4� 44,edl City
Lot Size ITax PIN# D
Subdivision Name(if applicable) 55 <%rM Section/I ot# Z,3
Directions To Site: '
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 ❑No
Are there any easements or right-of-ways on the site? ❑Yes ❑No
Is the site subject to approval by another public agency? ❑Yes ❑No
Will wastewater other than domestic sewage be generated? ❑Yes []No
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
Basement: ❑Yes ❑No Basement Plu 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:.*onventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: County/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
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
any permits) or ATC(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. 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.
Property owner's or owner's legal representative signature
09 n
Dat
Sign given ❑Yes ❑No
Revised 11/06
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account # r-622
Invoice # Z
SITE EVALUATION/IMPROVEMENT PERMIT & ATC
T,E'1�1,•.. '. . '.'..�JJV�(J.R-V/VV/..1'.AA �JJV�/Jl-V IVV.-: '. . ..� ..
'] lon/Improvement PermitXe
Authorization To Construct(ATC) ❑ Both
on: ❑New System ❑Repair to Existing Sy❑Expansion/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 �Q ('�� d /�%!�l✓ 710 1P �55�
Name to be Billed err U1h ke Contact Person t r 464K &lVel—.
Billing Address j9,6 Home Phone 70 —GG 4y
City/State/ZIP L -2 no Business Phone 336 — 7S/ -- 7300Z_
Name on Permit/AN if Diff than
Mailine Address P40 Aou
PROPERTY INFORMATION *Date House/Facility Comers Flaeeed
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 6 month with site p an, no expiration with complete plat.)
Owner's Name Z5G _'Col- Phone Number 3.36 �7S/-730
Owner's Address City/Statg/Zip
Property Address City Ci
Lot Size Tax PIN#
Subdivision ame(if applicable)_Secttioonn/Lot# 2-
Directions
Directions To Site: /�y/ ,x.8,.1 Mem Ks✓; P_. LL7'l ewJ r.1�. r-�t�.�l 11eLS%
If the answer to My of the following questions is `yes", supporting documentation to fst be attached.
Are there any existing wastewater systems on the site?
❑Yes kNo
Does the site contain jurisdictional wetlands?
❑Yes $qo
Are there any easements or right-of-ways on the site?
Ayes ❑No
Is the site subject to approval by another public agency?
XYes ❑No
Will wastewater other than domestic sewage be generated?
❑Yesxgo
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms Bathrooms1� Garden Tub/Whirlpool Wes ❑No
Basement: es ❑No Basement PlumbinR: 14es ❑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: lwiConventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: 16ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
If yes, what type?
k<
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s) or ATC(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. 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 comers and
locating and flagging ostaking the house/facility location proposed well location and the location of any other amenities.
Site Revisit Charge
7!;7;L�5'919'
leg representative signature
Date(s):
�R6Py yQ.� { Client Notification Date:
eVr EHS:
Sign given ❑Yes ❑No Account# g)22 --
Revised 11/06 Invoice # i��
Residential Permit Application
Davie County Development Services
172 Clement St.
Mocksville, NC 27028
(336) 753-6050
(336)751-7689 fax
Property Owner: 7ertv Blekke- cr
Address: 0 6
City/State/Zip: va..,L 700,
Phone#: Cell#: 7V41- 661- 7118-17
Contractor: o,.. LC., License#: SgDLIS
Address: 151-1 UL�
City/State/Zip:
Phone#:Inn- -W Cell#: (v- -
Site A ress:
City: Zw-? •, Subdivision: Esse-,,, r►-, . Lot#: �3
Description of Project: Res "
Water Supply: Public: ✓" Private(Well): NA:
Sewer Supply: Public: Septic: u, -" Septic Permit# NA:
I hereby attest the information provided on this application and any
additional information submitted pertaining to this application is true and
accurate. Should the use of the property and/or structures change, I
understand additional permits may be required. In addition, I understand
plan review cannot cover all aspects of construction and therefore any
work done will be required to meet all applicable local and state codes.
Signed: , Date: U
0 APP ON FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
2QO1 P.O. Box 848/210 Hospital Street
2 3 Mocksville, NC 27028
PSG (336)751-8760/ Fax (336)751-8786
ASN
��II? or: valuation/Improvement Permit ❑ Authorization To Construct(ATC) ❑ Both
EN`I\Roil' ation: ❑New System ❑Repair to Existing System ❑Expansion/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.
-W3
Name to be Billed ASC /0eyTe,*p"CN t C'yt_, i.•ac- Contact Person %oRRY .8476 vrl_
Billing Address Home Phone
City/State/ZIP _&Joos a&,r 4c- Z 7018 Business Phone 7S/ - 73oo
Name on Permit/ATC if Different than Above
Mailing Address Citv/State/Zip
FKUYLIKI Y 1NYUKMAIIUN ILate House/racntt L;omeIS I'Iaggea
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan lat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name Te A�1/6GoPrlFi�i ccKf I,IC. Phone Number 7S/ - 73"
Owner's Address 40 doh City/State/Zip &,?r s �icc�r /aG 2 7oLa
Property Address Cityy
Lot Size Tax PIN# , - IL
Subdivision Name(if applicable) , Essvx Fw.crr Sectioo/Lot# Z3 /1
If the answer to any of the following luestionsris "yes", supporting documentatiogg must be attfched.
Are there any existing wastewater systems on the site?
❑Yes QPp
200
Does the site contain jurisdictional wetlands?
❑Yes
Are there any easements or right-of-ways on the site?
Cies ❑ o
f�
Is the site subject to approval by another public agency?
❑Yes
Will wastewater other than domestic sewage be generated?
❑Yes (31�10
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms �•6 # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
Basement: ❑Yes ❑No Basement Plumbing: ❑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: KConventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: B`6ounty/City Water ❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
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 any permits) or ATC(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 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 comers and
locating an ging or staking the house/facility location, proposed well location and the location of any other amenities.
Site Revisit Charge
Prope r s or oer's legal represent§ re
Date(s):
7 Client Notification Date:
Date
EHS:
Sign given ❑Yes ❑No Account #
Revised 11/06 Invoice #