173 Redwood Drive Y-Lot 8Account #: 990004219
Billed To: Willie Perry
Reference Name:
Proposed Facility: Residence
ATC Number: 4571
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
OPERATION PERMIT l �j
Tax PIN/EH #: 5747-23-5386.08
Subdivision Info: Redwood/Southwood off Deadmon R
Location/Address: Redwood Drive -27028
Property Size: 3,1 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.
System Type: S.T. Manufacturer "�rl�* Ta4Date�*
Tank Size
Pum Tank Size—
P
iat.I. S ialis% %a
System Installed By: .pec /
�3
DCHD 11/06 (Revised)
�-t g
z! s
01
DAME 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 #: 990004219 Tax PIN/EH #: 5747-23-5386.08
Billed To: Willie Perry Subdivision Info: Redwood/Southwood off Deadmon R
Reference Name: Location/Address: Redwood Drive -27028 Sr f 73
.Proposed Facility: Residence Property Size: 3.1 acres
ATC Number: 4571
**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 FIVE YEARS. This ATC is subject to revocation if site plans, plat or
the intended use change.
Residential Specification: Building Type " — #People 3 #Bedrooms 3 #Baths 2 '
Basement w/Plumbing: T Basement/No Plumbing
Commercial Specification: Facility Type #People #People/Shift #Seats
Lot Size 31 Adi&'ype Water Supply (-w&W Design Wastewater Flow (GPD) 3fiD Site: New Repair
System Specifications: Tank Size (tom GAL. Pump Tank _ GAL. Trench Widths ' Trench Dept47-0- 32
Rock Depth IV LinearFt,
j� As stated in 15A NCAC 18A.1969(5)
Other: � 1 DMOJ&2Tl9a &SCS accepted Systems mayalso be used
Required Site Modifications/Conditions: �,'�a At1- S -�t�6Z 'yed
Contact th "e County Environmental Health Section for final inspection of this system etwb een C-FE:r--
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
56
mental Health Speci
t �
11/06 (Revised)
Davie Countv, -NC Tax Parcel Report Wednesdav, January 4, 2017
WARNING: THIS IS NOT A SURVEY
State:
Parcel Information
Zoning Overlay:
Parcel Number:
1<5070A0008
Township:
Mocksville
NCPIN Number:
5747235383
Municipality:
Fire Response District:
Account Number: -
82525682
Census Tract:
37059-805
Listed Owner 1c
-PERRY WILLIE S
Voting Precinct:
SOUTH MOCKSVILLE
Mailing Address 1:
173 REDWOOD DRIVE .'
Planning Jurisdiction:
Davie County
City' MOCKSVILLE
Plat Book:
Zoning Class:
DAVIE COUNTY R -A
State:
NC
Zoning Overlay:
Zip Code:
27028-5164
Voluntary Ag. District:
No
Legal Description:
LOT 8 SOUTHWOOD ACRES '
Fire Response District:
JERUSALEM
Assessed Acreage:
1.02
Elementary School Zone:
CORNATZER
Deed Date:
1/2006
Middle School Zone:
WILLIAM ELLIS
Deed Book / Page:
006441011
Soil Types:
PcC2,RnD
Plat Book:
0005
Flood Zone:
Plat Page:
065
Watershed Overlay:
DAVIE COUNTY
Outbuilding & Extra
Building Value'
Freatures Value:
Land Value:
Total Market Value:
Total Assessed Value:
9 oM�A
nDUN�
Davie County,
NC
All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Implied warranties of merchantability or fitness 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 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.
• APPLIC SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (336)751-8786
App t ` For: ❑ S. t�t�on/I vement Permit t' 'Authorization To Construct(ATC) ❑ Both
Type f Ap . a ,a 1 em ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***I7*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFO TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions�n.1
APPLICANT INFORMATION `�l'0olnc.4 /Viody - A
Name to be Billed
N II IE
Contact Person 4(11111,57-
d •
�,�
Billing Address
Home Phone
City/State/ZIP y
p� Business Phone
Name on Permit/ATC if Different than Above
Mailing Address
PROPERTY INFORMATION
*Date House/Facility Corners Flagged 1-13--0
NOTE: A survey plat or site plan must accompany this application.
(Permit is valid for 60 mont s with sit(kpl �, nQ expiration v
Owners Name 0� i S _�,P�c{ v dmf
Owner's Address 00 Al. dk6XV—)
Property Address
Lot Size / A(2XC Tax PIN#
Subdivision Name(if applicable)
Directions To Site: 10_ a/ '5-. j71-NWP Ou . a
Included: ❑ Site Plan ❑Plat(to scale)
k complete plat.)
-r-
City/State/Zip
City
Number
'11"'A
If the answer to any of the following questions is "yes", supporting documentationust be attached.
Are there any existing wastewater systems on the site? ❑Yes
Does the site contain jurisdictional wetlands? ❑Yeso
Are there any easements or right-of-ways on the site? ❑Yes1��10
Is the site subject to approval by another public agency? ❑Yes E o
Will wastewater other than domestic sewage be generated? ❑Yes W
TU "U 01 T U XTI 'Ll UTT T 11T TT TTJU n nN7 n OT n117
11' 1'1LL Vu 1 l llli YY
# People # Bedrooms 3 # Bathrooms t Z Garden Tub/Whirl ool es ❑No
P ��,,// P
Basement: ❑Yes o Basement Plumbing: ❑Yes X0 -
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 r
Type system requested: 16Conventional ❑ 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 viol",
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 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 fo the proper identification and labeling of property lines and corners and locating and flagging
or staking the house/facilityoca on, pr posed well location and the location of any other amenities.
/ / a . — � 0
Site Revisit Charge
Property owner's or owner's legal representativ ignature
Date(s):
/ Client Notification Date:
Date
EHS:
Sign given ❑Yes ❑No Account # 4,zlq
Revised 11/06 Invoice # „Q•
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336) 751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed 1pne en" [;n II7 Aro/# Contact Person L)Ad X uywmg�
Mailing Addresa QWj �9,e -t/E Home Phone 7..5-1 " Z 7 9 %
City/State/ZZPA1(A�iC�i/OL•LE': /YP• L70LX Business Phone
—�
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3. Application For: XSite Evaluationt4r g ❑ Improvement Permit/ATC ❑ Both
4. System to Services ; -,,Ouse ❑ Mobile Homo ❑ Business ❑ Industry ❑ Other
5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 13aCCep ted
6. If Residence: # People # Bedrooms 3 # Bathrooms 72---
Dishwasher ❑Garbage Disposal thing Machine ❑Basement/Plumbing ❑Basement/No Plumbing
7. If Business/Industry /Other: verify type # People # Sinks
# Commodes # Showers
IF FOODSERVICE: 0 Seats
8. Type of water supply: 0 Count y/City
# Urinals # Water Coolers
Estimated Water Usage (gallons per day)
❑ Well
❑ Community
9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes
If yes, what type?
CA -0
***IMPORTANT"`** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: /b X Z' V x Z, 10 X 3 4L WRITE DIRECTIONS (from r0ocksville) to PROPERTY:-
Tax Office PIN: 11 4.0,0 go g km e 4-S
7 3 - S3
Property A dre sl Road Name /R= -V W #e b ;M.
City/zip'Sd/GGC-Nth Zoo2S
If in a Subdivision provide information, as follows:
Name: cs� t. X hs.:) o o �-+� a�io ,✓
Section: Block: Lot:
C/
Date home corners (lagged: 7 6 S
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter arc subject to suspension or revocation, if the site plans or intended use change, or if the information
submitted in this application is falsified or clianged. I, also, understand that I am responsible for all charges incurred from
this application. I, hereby, give consent to the Authorized Representative of the Davie County IIcaltli 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 s ' bility. s
DATE 7— / .- h 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).
D
Sign given
Revised DCI -ID (05/03
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
Account No. S
Livoicc No. � �;
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/ Site Evaluation
APPLICANT INFORMATION
1
Account #:
990003495
Billed To:
Hendrix & Corriher Rental
Reference Name:
Proposed Facility:
Residence Property Size:
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
PROPERTY INFORMATION
Tax PIN/EH #: 5747-23-5383
Subdivision Info: Southwood Acres Lot # 08
Location/Address: Redwood Drive -27028
see map Date Evaluated: r77 122-
Community
Pit
Public a./
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
SS
S
Structure
5,
Mineralogy
_!5 ,
HORIZON II DEPTH
Texture groupC
• G
Consistence
,
Structure
k
Mineralogy
L,E
HORIZON III DEPTH
—
2 t 4
Texture group'
Consistence
Structure
MineralogyM/
HORIZON IV DEPTH
-
Texture group�i
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
0.2
SITE CLASSIFICATION: i%'S>
LONG-TERM ACCEPTANCE RATE:
REMARKS:
EVALUATION BY:
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
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
ui
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
NS - Non sticky SS - Slightly sti ky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plA.stic 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
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 05105 (Revised)