211 Bridle Lane Lot 2HEALTH DEPARTMENT RELEASE
A«S6l7Yro
Davie County Health Department
Y� ~ 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Address:
City:
Constance Reichelt
211 Bridle Lane
Advance
State0p: NC 27006
Phone #: (336) 354-6226
rr For Office Use Only
*CDP File Number 231595 - 2
5870318918
County ID Number:
evaluated For. HDR/WWC
PERMIT VAUD
UNTIL:
Property Owner: Constance Reichelt
Address: 211 Bridle Lane
City:
State/Zip:
Phone #:
Advance
NC 27006
(336) 354-6226
1-1 Property Location & Site Information
Address211 Bridle Lane Subdivision: Rabbit Farm Phase: 1 Lot: 2
Road # Advance NC 27006
SINGLE FAMILY Township:
*Structure: Directions
# of Bedrooms: 3 # of People: Hwy 64 East, left on Cornatzer Rd. On right before Shady Grove
School
*Water Supply: EXISTING WELL
Basement: n Yes ❑ No Type of Business:
Total sq. Footage: No. Of Employees:
*Proposed Improvement:
Bam 24x32
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? QYes "o
Applicant/Legal Reps. Signature; *Date: /
*Issued By: 2140 -Nations, Robert *Date of Issue: 0 1/ 1 6/ 2 0 1 7
Authorized State Age
**Site Plan/Drawing attached.**
CDHand Drawing OImport Drawing
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.
231595 - 2'
County File Number: 5870318918
Date: 01/ 1 6/ 2 0 1 7
0Inch
Scale:
()Block
Q N/A
Davie Count} Health Department
4
1836 Envy onmental Health Section jr ,
. . P.O. Box 848 F r
210 Hospital Street
Q ZT� Courier # : 09-10-06 j c�
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name:11(_' &1'ck Phone Number (Home)
Mailing Address: W-e,talle 3 3(p �✓�� �Z Z (o (Work)
accr�a�.�2-
Detailed Directions To
Property Address: 02/ //Zi G l e (Ayr
Please Fill In The Following
�Information About The EYJSTING Facility:
Name System Installed Under:( 1 d(Z Ise S ! O nt li Type Of Facility: S
Date System Installed (Month./Date/Year): 0 3 Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In Thelowing Information About The NEIV Facility:
Type Of Facility: 6 l2 N �� X 3a Number Of Bedrooms: Number of People
Pool Size:
XRequested By:
Garage Size: Other:
Requested: TDI.. 63 QL'y
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*The signing of this fonn 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:$ AU -00 Date:
Paid By: Received By:
Account #: Invoice #'. b le 1-1,0-17
Davie County, NC
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WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number:.
G70000013916
Township:
Shady Grove
NCPIN Number:
5870318918
Municipality:
Account Number:
8307149
Census Tract:
37059-804
Listed Owner :1: - - . - _
BAHM CHRISTOPHER '`.
Voting Precinct:
EAST SHADY GROVE
Mailing Address 1:
211 BRIDLE LANE .. ;
Planning Jurisdiction:
Davie County
City: ADVANCE._. ':
Zoning Class: DAVIE COUNTY R-A,R-20
State:
NC
Zoning Overlay:
Zip Code:
27006
Voluntary Ag. District:
Legal Description:.. _
LOT 2 RABBIT FARM PHASE I
Fire Response District:
ADVANCE
Assessed Acreage:
5.02
Elementary School Zone:
SHADY GROVE
Deed Date:
11/2016
Middle School Zone:
WILLIAM ELLIS
Deed Book / Page:
010341083
Soil Types:
GnB2,GnC2
Plat Book:
0006
Flood Zone:
Plat Page:
071
Watershed Overlay:
DAVIE COUNTY
Building Value:
Outbuilding & Extra
Freatures Value:
Land Value:
Total Market Value:
Total Assessed Value:
No
!017
O m�FAll data Is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
NC County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to
- or arising out of the use or inability to use the GIS data provided by this website.
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DAVIE COUNTY ' HEALTH ' DEPARTMENT y
IMPROVEMENTSPERMIT AND CERTIFICATE OF OMPLETION
j�..*NOTE: Issued in Compliance With Artie 11 of G.S. Chapter 130a o2/% 8%%9 `Q� r
Sanitary Sewage Systems
Permit 7Nulmbe�
Name c �, AR 2S W O i`c�* 1 Date - 1 N� 71 81
location � 5 ��filQ�t Q � � • a$ ��9
E Ll
.oma,
Subdivision Name-� Lot No. Sec. or Block No.
Lot Size�p q— House :U Mobile Home _T Business ' Industry
No.' Bedrooms No.?Baths ^�3 No. in• Family 3 Public Assembly Other
Garbage Disposal YES " g/' NO, p r Specifications for ,System:
o
Auto Dish Washer YES [7� NO E] `, be C<Z)
Auto Wash Ma^hine.' �, YES��''NO
Type Water SuRpIY �� ---map"
This permit if s4 a' em escribed below isnot installed within 5 years from date of issue. 3
This permit is , bj_ o,revocation'°if s' ` use`change ? '
_q
1--� �,60,
t 1
Improvements permit by -- ��
•Contact a representative of the Davie County.Heahh Department for final -inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30=.5:00 P.M. on day of completion. Telephone Number: 704634-5985. !
Final Installation Diagram:;' System Installed by\
� 1�w •mr-..�r�� 1 t1010
r. loci ;
• w
11 Certificate of Completion Date
'The signing of this certificate shall indicate that the system described above has been installed -in compliance with
the standards set forth in the above regulation, but shall in. NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time. b
• APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT \ ! 1
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By Q,,A P. f4 -.Q 0. 7e mpJ/ �7 A) S' 'f ' /
Mnilinn ArlrlrAcc .A A- / 2 7—A o R N 9-b Q 0 ri 1C YO L A c, ' - eh A R L r_ � �/ • C. Z Y 16,9
Home Phone "7 a � - 9 ? ? / ? % Business Phoner "l # 411595 - Y 2/ Y fi
2. Name on Permit if Different than Above c5O m Z'
3. Application/Permit for: jg General Evaluation J( Septic Tank Installation
4. System to Serve: House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision NO Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms Washing Machine
No. of Bathrooms 2 j�� - Dishwasher
Dwelling Dimensions 2 0 O 0 std . ��. ' � i � � Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type N /�
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 _
7. Type of water supply: ❑ Public A Private
8. Property Dimensions SSewage Disposal Contractor
9. Do you anticipate
If yes, what type?
of the facility this sytem is intended to serve? ❑ Yes X No
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date Issue&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 of my knowledge, and I understand I am responsible for all charges
Incurred from this application.
i 0 /9 y1 X 2 9`1 �� a.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO ,BE DONE ON ABOVE pESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. X 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 of th Da ie County Hea th Depart ent o enter upon above described
property located in Davie County and owned by _ 2 7¢Y
to conduct all testing procedures as necessary to,deterrhrre said site's suitability for a ground absorpti n sewage treatment
and disposal system/. /
DATE SIGNA , E
DCHD (12.90)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME DATE EVALUATED 6 3 1 -9 L+
ADDRESS l \ PROPERTY SIZE Cp \
PROPOSED FACIILTY r °- LOCATION OF SITE
Water Supply: On -Site Well ✓ Community
Evaluation By:CMZ- Auger BoringPit____
Public
Cut
FACTORS
1
2
3
4
Landscape position
S
S
--'�Z
Slope %
I' - Is
T
r 77
' S
HORIZON I DEPTH
1'
- t,.''
"
"
Texture group
LCl—
Consistence
�.
Structure
C
"�
CV.-
Mineralogy
VA
HORIZON II DEPTH
14
4Z`
Texture group
ConsistenceFx-
Structure
Mineralogy;
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
Gam.
SS
RESTRICTIVE HORIZON--
SAPROLITE
"
--
CLASSIFICATION
5.
S
-.S
LONG-TERM ACCEPTANCE RATEJ
31
SITE CLASSIFICATION: "X2'5
LONG-TERM ACCEPTANCE RATE: 1%
REMARKS: �� � VN
DCHD (01-901
EVALUATED BY: C31.
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
qr-til-
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
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