202 Bethlehem Drive Lot 3'HEALTH DEPARTMENT RELEASE
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Davie County Health Department
210 Hospital Street
.� P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Tari Koty
Address: 202 Bethlehem Drive
City: Advance
State2ip: NC 27006
Phone #: (336) 940-3682
For Office Use Only
*CDP File Number 198394-1
County ID Number.
valuated For: HDR/WWC
PERMIT VALID 1 a/ 0 7/ a 0 a 0
UNTIL:
Property Owner: Tari Koty
Address: 202 Bethlehem Drive
City: Advance
State0p: NC 27006
Phone #: (336) 940-3682
Property Location & Site Information
Address202 Bethlehem Drive Subdivision: Redland Way
Road # Adance NC 27006
SINGLE FAMILY Township:
'Structure: Directions
# of Bedrooms: 3 4 of People: Hwy 158, loft on Longwood Drive at Redland Way, take left on
Bethleham Drive, 1st house on left
Phase: Lot: 3
Vater Supply: NIA
Basement: n Yes n No
"Proposed improvement:
Deck 21 x18
Type of Business:
Total sq. Footage: No. Of Employees:
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? 4Yes ONo
Applicant/Legal Reps. Signature', 'Date: /
'Issued By: 2140 -Nations, Robert *Date of Issue: 1 a 0 7/ a 0 1 5
Authorized State Agen
**Site Plan/Drawing attached.**
a Hand Drawing 4lmport 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:
198394 -1
County File Number:
Date: 12/03/.2015
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,RECEIVED
NOV 0 3 2015
DC HEALTH Davie County Health Department
9 18 ftp` Environmental Health Section
PAID 1'.0.13ox 848
ate; Q j- 210 Hospital Strcct
O11 Fteeeived b ; Courier #: 09-40-06
Mocksvillc, NC 27028
Phone: (336) - 753 - 6780
ON-SITE WASTEWATER CERTIFIQATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: Tari Koty Phone Number 336-940-3682 (Home)
Mailing Address: 209 Bethlehem Drive
�. K I • ei •
Detailed Directions To Site: From US 158, turn left onto Longwood Drive, at Redland Way Plan.
From Longwood Drive, take left onto Bethlehem Drive. House is 1st house on left
Property Address: 202 Bethlehem Drive I
-Lo4
Please Fill In The Following Information About The EXISTING Facility: Q liaf -fa
Name System Installed Under:
Type Of Facility: Residence
Date System Installed (Month/Date/Year): 12/31/2003 Number Of Bedrooms: 3 Number Of People: 3
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Residence Number Of Bedrooms: Number of People
P001 Size Garage Size: Other: Deck 21 ' X 18 '
'Approved Disapproved
/1n
ments. . 11 11
For Environmental Health Office Use Only
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Environmental Health Specialist Date: f 7 — 7 —155 _
*The signing of this form by the Environmental Health`5taff is in no way intended, nor should be taken as a guarantee
(extended ori ited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash ( Check )Money Order #.
Amount:$ Date:
Paid By: Received By:
Account #: 2 311q Invoice;
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' DAVIE COUNTY HEALTH DEPARTMENT —7—A) V
• Environmental Health Section
P. O. Boa 848/210 Hospital Street fL` b-- 4,
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002436 Tax PIN/EH #: 5861-59-5348.DB
Billed To: Darren Burke Constr. Subdivision Info: Redland Way Lot # 03
Reference Name: Location/Address: Bethlehem Drive -27006
Proposed Facility: Residence
Property Size: se map
ATC Nrnber: 3497
**NOTE** is 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 jj
Specification: Building Type #People#Bedrooms #Baths 2
Dishwasher: Garbage Disposal: ❑ Washing Machine: M Basement w/Plumbing: u Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size I. C)-7 -Aype Water Supply �� %YDesign Wastewater Flow (GPD)--��20 Site: New Repair ❑
System Specifications: Tank Size 1X0 GAL. Pump Tank GAL. Trench IA57-44-t,
idth a Rock Depth 2 Linear Ft.
Other: c '/1Si�!5,0Tto J 3i�t� Lilt -:6 C7•C. A—
Required Site Modifications/Conditions: hal;f- — 4�� 10'
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
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 Health Spec ali is Signature: ?o • Da e:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital street
Mocksville, NC 27028
(336)751-8760
Account #: 990002436 Tax PIN/EH #: 5861-59-5348.DB
Billed To: Darren Burke Constr. Subdivision Info: Redland Way Lot # 03
Reference Name: Location/Address: Bethlehem Drive -27006
Proposed Facility: Residence Property Size: se ma
ATC Number: 3497
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, Section .1900 Sew a Trea t and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW S TI A ID FOR A PERIOD OF IVE ARS.
7 --Environmental Health Specialist's Signatu Dat
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the s
has been installed in compliance with Article 11 of G.S. Ch er 130A,
Disposal Systems," but shall in NOWAY betaken as a grantee 1hatl
given period of time. 17-Q
It,
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
to
scribed on Improvement/Operation Permit
0ion .1900 "Sewage Treatment and
system will function satisfactorily for any
to
40os-,S,
V- -T-Vtt,�S,-OJ
Date: PlAs Ll
Jun 25,03 08:47a Darren Burke 336-778-0436
Jun IU.03 11:14a davie county envheaith 339 751 8786 p_2
APPucA.uav Fou SUE EVALVA7I0N(1MPIIDWFAtfN7 PCIUHr u n7c
Davie County Health Department
E/Iy1Aw7mW4a/H0 A*SeCN0,7
F.O. Box 840/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
f ++•rm"RrAArT++• Tias APkLIcATYON CANNOT 88 PROCESSED UNLESS ALL THE REQUIRED f
I i:NFORKATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructiono.
r
1. name to he oil led . r` C . Contact P.t.an!QAer Y
l�{�//
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' +
)tailing Addreaa
Clf�L
City/Sute/ZIP t�i'SrT /0Ioe.. Buaiasos Phan•
2. nteo w Permit/OTC it Ditftreot than above �!/I'&—_
�,flog 44drtaa
3. Application For: ❑ Sito ?tialnation 13 Improvement Permit/ATC
Both
4. system to secviea. Hausa ❑ Mobile HOIDe ❑ Business ❑ Industry D Othcr
5. Type eyatee requeetede p t35aveational E3 eonwontioaal modified Q lnnovati•c
S
3
.nf
Ole
A. IItRRoaidonce: • PPeoople B Bedr�o/Ona a BatitTOotas
OW1Mvisher Qfarbess Dirpwa2 machine pt -a cat/PZ..WGg ❑Daaew t/Mo el—bin.i
/ `
/*—ag
7. if suaieeta/Industry /Other: verity type a P-WIe a Sinks
__^
a C—dea B 5howro . ♦ Dr,imals a Mate• Cooler.
Ir POODSERVICE: 0 Beata Ratimated hater usage IQallena par day)
e. Type of —tnrsupply�CoaYtT/City D Hn3.1 ❑ cownunity
P. Do you antfcipato adds cions or expansions or the facility this system Is intended to scrvcy. 13 Yes )(N..
Irycs, wisal t)•pe9
•++IMPORTAltl1's++CLIFX'SMUS) COMPLET@THE REQUIRED PAOPEICI'Y INFORMATION 1IL•'Q11 l >
BELOW. Either PLAT er51TEQFL�1N MI1(/STBESUBMITTED by the client with THIS APPLICA'CION.
ProperlyDirncasions: �/ / X.� %dl,j{i�01 IVRIT6DlRECItON5(five,hlurbvitic)totDI'tltT
Tax Office 111 D J � 9' S 3'Y p t 0' 15 g / 9j �J 9C �rY/4 •0,
�
Property Address: Road Name _16t' AI'lloy or-
Cilymp 4 « !��
If in a Subdivaloi rityidc informa-ion, as foltotvs:
lvatns: ` i��
Section: 11lock: Lot:
Date home corners flagged: 2- • L3
This is to certify that theinformatioa provided Is correct to Use best ormy kuotvledge. I anderstaind that any permil(s)
lswcd hereafter are subject to suspension or revocation, if tho site plans or lntended use change, or if the iuloruutiou
submitted in ibis application is fahlfa d or changed. Ir also, andivs/andthal I ars reslmusi7dejur all charges lecanrtvlJroar
this opplicarion. 1, hereby, give consent to the Authorized Representative of the Davie County Ileaffit
rN ar( n 4
to enter upon above described property Inched in Davie County and osuned by
to conduct all testing procedures as mxessary to determiuo the site suilabilkM
DATE lrh --S ` 0 "-, StGNATURE
THIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (fucludtidR of tike following: Existing and proposed
property Oars and dimensions, structures, setbacks, and septic locations).
Sign given
Revised DCHD (05/03
Site Revisit Charge
Datc(s):
Notification Date:
Account No. _. —
p.1
j& 7' -JC
? sG,4!!
1,10
Invoice No. S'6 r ` Com--
Jun 25 03 08:47a Darren Burke
160.8501
W
336-778-0436
I j 32. 000 1
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Redland Way
Lot 3
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1.068 AcA
N 86'1643" w
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1.068 Ac.t
S 86-20'13" W
161.74' Total
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APPLICATION I.OII SMC EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health SeWon
P.O. Box 848/210 Hospital Street
Mockoville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCRSBND UNLESS ALL
INIrORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for
1. Naso to be Billed
Contact Person
[JUN
EtEbUJUD
NTAI
�.VIVIE COUNIY
Mailing Address cl" k4 J t Home Phone % %S
City/state/LIP/�(✓,
-�> Business Phone
2. Name on Perwit/ATC if Different than Above
Nailing Address/� city/state/zip
3. Application Sor: V/Site Evaluation 0 Improvement Permit/ATC ❑ Both
*. system to servioet 9"House 0 Mobile Home 0 Business 0 Industry ❑ Other VIA.....
5. If Residence: # People
1 Bedrooms
❑ Dishwasher ❑ Garbage Disposal ❑ hashing Machine
6. If Business/Industry/Others Specify type
# Commodes 1 Showers
❑ Basenant/Plumbing
II People _
# Urinals
1 Bathrooms
❑ Bassmant/No Plumbing
/ Sinks
# Nater Coolers
Ir FOODSERVICE: 11 Seats Estimated Water Usage (gallons per day)
z. Type of water supply: 91County/City D Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes 0 No
If yes, what type?
"**IMPORTANT*** CLIENTS MUST CO'MPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: _ %i r6,5 WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: it ��jv ._�� — S�3`i °3 1S • 5q n p LI , '�2
Property Address: Road Name �wc
City/Zip A&IWee, l,/ -if
If In a Subdivision provide Information, as follows: % 4-
Name: P ;( /,,_ .�
Section: Block: Lot: 13 Date Property Flagged:
This Is to certify that the information provided h 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 1 am responsible for all charges Incurred from
this appficadom I, 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 sultal lilty.
DATE _ y `G�� 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).
Site Revisit Charge
Date(s):
I Client Notification Date:
I EIIS:
Revised DCIID (07199)
Account No.
Invoice No.
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 989900136 Tax PIN/EH #: 5861-59-5239.03
Billed To: Westview Development Co. Subdivision Info: Redland Lot # 3
Reference Name: Location/Address: LISHighway 158-27006
Proposed Facility: Residence Property Size: see map Date Evaluated: -71&101 _
Water Supply:
On -Site Well Community
Evaluation By: Auger Boring Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
Sloe %
HORIZON I DEPTH
0
Texture group
Consistence
S
Structure
:5f'k-
Mineralogy
1.7
HORIZON II DEPTH
-I }j
Texture group
Consistence
Structure
S 11511
5
Mineralogy/
HORIZON III DEPTH
Texture group,
-
Consistence
(�
Structure
S
Mineralogyi
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
L) -s
LONG-TERM ACCEPTANCE RATE
,3
SITE CLASSIFICATION: PS EVALUATION BY:
LONG-TERM ACCEPTANCE RATE. () - 3 OTHER(S) PRESENT:
REMARKS: _K_.(il �L t"AI X t�o 1 �`' CA_ P4 2 -
LEGEND LEGEND
Landscane 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
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)
Davie County Health Department
9 his " Environmental Health Section
P.O. Box 848 ,
210 Hospital Street
O �'t Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680
(Check One) Replacement Remodeling Reconnection
S jj//
Au�q dol %rte
&Ipi Name:C C t�1 U Phone Number 14' ZQ Ltd 2 (Home)
Mailing Address: ZUZ-1 �, ��i�bl 1 (1 l /2 • (Work)
i / V ( C'- /V[ 77Ud Email Address:
Detailed Directions To Site:
�►-
Property Address:
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: 1',, _¢) f f f �j / �C � Type Of Facility: U50
Date System Installed (Month/Date/Year): Z .1 G � Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes ( No�
If Yes, For How Long?
Any Known Problems? Yes ON If Yes, Explain:
Please Fill In The Following Information Ab/out The NEW Facility:
Type Of Facility: -e V i yu �'o / cif -� ' Z a 1 Number Of Bedrooms: Number of People.
Pool Size: / Garage Size: Other:
Requested By: /,f , / Date Requested:
(Signature)
For Environmental Health Office Use Only
Disapproved
Environmental Health Specialist.
Date: n / Mr/ / 7 -
*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:$ Date:
Paid By: Received By:
Account #: Invoice #:
GoMAPS - Davie County NC Public Access
***WARNING: THIS IS NOT A SURVEY!***
This map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map.
BERMUDA RUN
COOLEEMEE
DAVIE COUNTY
MOCKSVILLE
Wednesday, August 15 2012
WATERSHED STRUCTURES
WATER BODIES
COUNTY -BOUNDARY
®
ADDRESS
i
DRIVES
i
STREETS
RAILROAD_ CENTERLINE
PARCELS
2010Aerial_Photos
C(TY_LIMITS
BERMUDA RUN
COOLEEMEE
DAVIE COUNTY
MOCKSVILLE
Wednesday, August 15 2012