203 Shady Grove Lane Lot 14AU,THORIZAIION NO: Q g 19 DAVIE COUNTY HEALTH DEPARTMENT
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Environmental Health Section
PROPERTY INFORMATION '
Permntee4s`—;
P.O..Box 848,
Mocksville, NC 27028
Subdivision Name:
Directions to property:
Phone #: 704-634-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER
Tax Office OfF PIN # I6ris !
SYSTEM CONSTRUCTION -
Road
am f ++-� lado, :VO4
**NOTE** This Authorization for Wastewater System Construction MUSYBE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This FomVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits. ; 1. . 1.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
F �! IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTALHEALTHSPECIALIST:. DATE ISSUED
r W,.•n r rt,yx^v' .. lonumurr v'Wf7PMti•=l�Xn"ruy.�,ry ttii"kFr+S�y:� �}F'tiiMC�r+'JQ%3'1�,WiNuu x'1THf V{n,,., kV�rnt _..�wrk;li�p�t'i,�;i.>X`05
[�
w DAVIE COUNTY HEALTH DEPARTMENT .
Pe C IMPROVEMENT AND OPERATION PERMITS , PROPERTY. INFORMATION
Subdivision Name:
Directions to property: Section Lot: L_4 _
IMPROVEMENT
PERMIT Tax Office PIN:# ! 16 ! -
Road Name: — 0 6 �
**NOTE**- This Improvement Permit DOES NOT authorize the construction of installation of a septic tank system or any wastewater systenL.M '
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION, must be obtained from this Department prior to the,--
construction/installation
he` constmction/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)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
'�u 'i��" 'l/'-'_�t._ ✓� -t ✓ ". PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ,
'ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE -
INSTALLING THE SYSTEM . .
RESIDENTIALSPECIFI . '. ',, - —r:''--
CAITON: BUILDING TYPE--- #BEDROOMS # BATHS # OCCUPANTS _� GARBAGE DISPOSAL: Yes o�
COMMERCIAL SPECIFICATION: FACILITY TYPE +- J . # PEOPLE # PEOPLE/SHIFT # SEATS _,INDUSTRIAL; WASTE: Yes or No
LOT SIZE' TYPE WATER SUPPLY - - e/ - ,DESIGN WASTEWATER FLOW (GPD) �.NEW SITE v/REPAIR SITE
ADD -
SYSTEM SPECIFICATIONS: TANK -SIZE GAL. PUMP TANK GAL. TRENCH WIDTH F,'/"ROCK DEPTH LINEAR Fr.,5'w'
r
OTHER - i • ..
REQUIRED SITE.MODIFICATIONS/CONDUTONS: r(L.J ' �ey -
**CONTACT A REPRESENTATIVE OF THE DAVIE. COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 6348760.
- DCHD 05/96 (Revised) - - - -
APPLICATION FOR SITE EVALUATIONAMPROVEMENT
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704)634-8760
I L
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED 1
THE REQUIRED INFORMATION IS PROVIDED.
& ATC
JUN 1 91997
1. Name to be Billed I XAK j=t� Contact Person i hAc--OA ''/VCS 4�
Mailing Address Home Phone ��^ y37G%
City/State/Zip Ce AJC Business Phone llo
2. Name on Permit/ATC if Different than Above �bv +
Mailing Address City/State/Zip
3. Application For: [ Site Evaluation Mlmprovement Permit & ATC [ ] Both
4. System to Serve: [ use [ ] Mobile Home [ .] Business [ ] Industry
5. If Residence: # People, #Bedrooms r� # Bathrooms rte_
[o (Washing Machine [ ] Basement/Plumbing [LKasement/No Plumbing
6. If Business/Other: Specify
# Showers # Urinals # Water Coolers
r 1 nther
P�Kishwasher [ ] Garbage Disposal
# People #Sinks # Commodes
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply:County/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [-]14o
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** AtFfOF THE PROPERTY MUST BE
I
y SUBMITTED WITH TfH$ APPLICATION.
Property Dimensions: ll ��-!"' a — WRITE DIRECTIONS (from [1loCksville) TO PROPERTY:
Tax Office PIN: #<MM_rte- �3 r / - ��r b d
Property Address: Road Nam.2�03// J1faA A,44-je 4>
k1City/Zip �/`7 �1 f/ Ale �9 ?OC6 ; I,& k
If in Subdivision provide information, as follows:
Name: l��C/-� --=
Section: Lot#: IT - - C
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
Rep�resentative of the Davie County Health Department to enter upon above described property located in Davie County and owned
�' j_r/ kc"' to nduc all t ting rocedures as necessary to de rmine the ite suitability.
DATE SIGNATURE n �1° % GT U� CvS
Revised DCHD (06-96)
THIS AREA MAY BE USED FOR bRAWING IYOUR.SITE PLAN:
r _.
E1C�L SU'3DIVISION P� _T _Qf sLCi''_TF���_APPRQY_AL
"1 herebycertify that the subdivision plat :.'hown hereon has been me foregoing eertl icate of I `• r
y p 9 9 .��r. Filed for Reglsfratlon of L
found to corn, ly with the Cdbnty Subdivision Regulations, with the . (HERE GiVE NAME i o ihhe
exception of such variances, if any, as ore noted in the minutes /V f'G this day of a, h1F
of the Planning Board and that It has been approved for recording AND OM
CIAL i1TLE OF THE OFFICER SIGNING Plat BC ',k — Pae 1
In the office of Register of Deeds. It Is hereby noted that such �QL1 •� n Q
approval for r:tcordation dove not Include approval to Install and ( so QA4 V LL_ _
utilize sanitary facilities nor does it include approval for the THE CERTIFlCATE PASSED UPON) / / cn
construction or.occuponcy of buildings or structures." nloVG�bei— Henry Sh
111r)U�r+do2 � da of G.6.ier, 1996. Filing F,j Paid b
This + � '+ay of 1 96. Is certified to be correct. This y 9 Y
' Probate fee paid. � .
by Henr�ore, Register of Deeds Depoy - Assistant
tractor, Davie County P66nning Department
3
4CERTIFICATE OF APPROVAL BY THE PLANNING BOARD:
The D '•• Ccs qty Planning Board hereby approves the final plot for 'SHADY GROVE' Subdivision.
This thP. ray of October 1996. .. 86 ?G. 5
. Chairman, County Planning Board
D.B•
1.
CONC.
CONTROL
CORNER -I---TOTAL 1602.72' S
NIP' i `13400'
22.0 130.00' 138.00' 149.72'
191.00'
.
I
Y
�. w cW W
O �p p
CV
00
C�
O \ \ r0 O
"Or U-) u')
I I o I I d I (q
r
N —J N 6� ��-----_—
C: M93.25' 93.25'_—_ _____124_91 _ 8--- J .0 TOTAL 1/h� \C �f _TOTAL _ _305.94' N 9' 53' 49" E C: K
N ---- 20' _PAVED PUBLIC ROAD. ---_C2
W — ------_�— _ _ _ _ _
17" �-
S 2'.16 01' �� ��� ---- -- — ------------
0 --- —�? — --- —
160. l'
tT \�� _ � 15.00' 140.00' 150.94' �\\ I— fi __ ---- Ld ---
- --1
r
'LL ' CO
W W J� I
�. �
0 I '00
01 d am00
N
�t . l L - f N ro ro - -
N I / I I / L
• l 1. �i `�.._. � CV
/^in O
ry N
78.00' 194.00' 140.00'
136.00' 66.77.' E1P
--:I-TOTAL 614.77' N 7' 37' 2" E
EIP
�CONC.
PARCEL, 19 CONTROL
W. J. ELLIS CORNER
-DB. 53 PG. 296
ZONED R-20
ed
t
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
-T
PROPERTY SIZE_
LOCATION OF SITE
Water Supply: - On -Site Well Community - 'Public [/
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L
Slope S
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH *-
Texture rou
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE —
SITE CLASSIFICATION: EVALUATED BY: /z
LONG-TERM ACCEPTANCE RATE: __Ly___ 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 :lay loam SIL -Silty loam CL -Clay loam - SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
Moist
VFR- Very friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm
Wet
NS -Non sticky SS -Slightly sticky S -Sticky - VS -Very Sticky
NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic
Structure
,3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors
with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD(01-901