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1803 Cana Rd 4 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital.Street Mocksville,NC 27628 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990003585 Tax PIN/EH#: 583241-401942 (system) Billed To: Mariana Maldjian Subdivision Info: Reference Name: Location/Address: 1803 Cana Road-27028 Proposed Facility: Residence_ Property Size: 63 Acres ATC Number: 4628 **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. \��A System Type: 5 S.T.Manufacturer Tank Date TankSize Pump Tank Size System Installed By: �rA s��" E.H. Specialist: Date: — d-7-67 (7ar,�a �C, ( wh�J c �� _ �r�J.R. �✓ a --_ — 10d too too /* ` \� � VVOL , • DCHD 11/06(Revised) " 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 #: 990003585 Tax PIN/EH#: 5832-21-4019-#2 (system) Billed To: Mariana Maldjian Subdivision Info: Reference Name: Location/Address: 1803 Cana Road-27028 Proposed Facility: Residence Property Size: 63 Acres ATC Number: 4628 Site Type: ❑New ❑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 1-1 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 #Bathrooms #People Basement asement plumbing{'' Non=Residential Specifications: Facility Type #People #Seats r Square Footage(or Dimensions of Facility)_/_ Lot Si2Xb-37At Cr4S- " "Type of Water'Supply. ❑County/City dwell ❑Community Well System Specifications: Design Wastewater Flow(GPD)3—(66 Tank Size I AGAL.Pump Tank GAL. Trench Width 3Q IMirx.Trench Depth<<'Rock Depth Linear Ft. 3d� .As wated in 15A N-CAC 184ji�69 5 � .Site Modifications/Conditions/Other: '9t'•0�3Ate �' a' Contact the Davie County Environmental Health.Section for final inspection of this system between 8:30=9:30a.m.on tfie da of,installation._Tele hone#(336)751-8760. e�y I °g; CQ Iy'`P t I t l\ tiov o � Baa i �9 � \ `� M i/l �J eve • _ ap �—Ip n �t0 0 L Cc-, o &-t-Cr �aL- r7C7 _ Environmental Health Specialist - Date: DCHD 11106(Revised) DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street (2. Mocksville,NC 27028 (336 )751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990003585 Tax PIN/EH#: 5832-21-4019-#2 (system) Billed To: Mariana Maldjian Subdivision Info: Reference Name: Location/Address: 1803 Cana Road-27028 Proposed Facirty: Residence: Property Size: 63 Acres ATC Number: 4628 Site Type: ❑New ❑Repair ffExpansion **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 3 #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size 63 qc/'G 5 Type of Water Supply: ❑County/City B'4'ell ❑Community Well System Specifications: Design Wastewater Flow(GPD) 3420 Tank Size l dcVGAL.Pump Tank&,�/4 GAL. Trench Width 34 << Max.Trench Depth 3G !eRock Depth 11" Linear Ft. 4r Q Site Modifications/Conditions/Other: As stated in 15A NCRC 113.4.19,69(57 ceepted Sysienns—may also be us - 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. Site Plan FyC f`r Oto -eY-C dJ e C_ -5y/11Yb"j, itc- l r.'e , � y:l f�✓ �f'O zt/ �O�- .� ' : �-t..(c� ,i 6.1 r �•�, �11we� SYrY�c 11 q - u C( 4 //d f!n/e 5-1 too j' \�` � �� CA 14 ,N ``J r7/"G P'ecA.✓ Ic Environmental Health Specialist Date i.p.l 1-06 Davie County Environmental Health. P.O.tBox 848/210 Hospital Street 1VIocksville N6, 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990003585 Tax PIN/EH#: 5832-21-4019-#2 (system) Billed To: Mariana Maldjian Subdivision Info: Address: 1803 Cana Road Location/Address: 1803 Cana Road-27028 City: Mocksville Property Size: 63 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: ew ❑Repair xpansion Permit Valid for: Years ❑No Expiration Residential Specifications: #Bedrooms--3 #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): 34-0 Type of Water Supply: ❑County/City ❑1�ell ❑CommunityWell Site Modifications/Permit Conditions: As stated in 15A NCAC 18A.1989(5) cepted-Spnte. s may-albU U11 u e stem T e LTAR Initial Repair S Site Plan w , Fit- Environmental Health Specialist Date 3 — v i.p.11-06 r r Jan 22 07 10: 13a clavie county envhealth 336 751 8786 P.2 \`vll N FOR SITE EVALIJATION/IM:PROVEMENI'PERMIT&ATC Davie County Environmental Health P.O. C Q rZ ` LOO 0 Hospital Street Mocksville,NC 27028 )�? Please-add i ?j EB (336)751-8760/Fax(336),51-87865 I` h �� n i 0C Site al ionln.provement Permit 0 Authorization To Construct(ATC) 0 Both licati F.N�R4 VI � ew S sten0Repair to Ex.istin*g S stem OEx nsion/Modification n fExisting System or Facility **IMPORTANT***THIS APPLIC,\TION CANNOTBE PROCESSED UNLESS ALL OF TI IE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed 0LdMCA\C\,i A,n Ce ntact Person6na Billing Address SCa 2 rein,?,_ 9a 1 tome Phone 3.30 Q!Ao City/State/ZIP-1.J1n E C ev t1\L 1\3 C– 2-10 2 Y, Business Phone \ \�� Name on PermiVATC if D Brent than Above ( 0 O Mailing Address City/State/Zip— PROPERTY INFORMATION *Date Hous(!/Facility Comers I•laggcd ,\� f� NOTE: A survey plat or site plan must accompany this application Included: ite Plan OPlat(to scale) ` 1gfO `x (Permit i'valid for 60 months.vith site plan,no expiration with complete plat.) �5 Owner's Name ' ' Phone Numb-5 q 11 Owner's Address O City/State/Zip�)G0y�\ 1J 27o7-K () Property Address City Lot Size_ 6`2� ac _ _ Tax PINI/ _ Subdivision Name(ifapplicable)` Q Section/Lot# N/A Directions To Site:( ,� _ g�nc aV�_ �/ �,20e(INS OSA- kU0 o w If etit answer to any of the following questions is"yes",supporting doe u.tion must be attached. Are there any existing wastewa.er systems on the site? Wes lo Does the site contain jurisdicticnal wetlands? OYes Are there any easements or rigkr-of-ways on the site? Oyes Is the site subject to approval b;,another public agency? OYes Will wastewater othei than domestic sewage be generated? OYes IF RESIDENCE FILL OUT TI-H:BOX BELOW #People #Bedrooms _j_ Bathrooms_ Garden Tub/Whirlpool We ONo Bascrncnt: es C1No BascmcntPlumbing. Yes ONo IF NON-RESIDENCE FILL OU_r THE BOX BELOW Type of Facility/Bbsiness — Total Square Footage of Building #People #Sinks #Commodes_ #Showers #Urinals_ Estimated Water Usage(gallons per-.'ay) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested:.trKonventional UAccepted Olnnovative OAltenative UOther Water Supply Type:0 County/City Watt_ ew Well OEx sting Well 0 qoaununity Well Do you anticipate additions or expansions of the facility this system is intender:.to serve?0 Yes tutu. nt3ube— . If yes,what type? — n This is to certify that the inforination provided on this application is true and correct to the best of my knowledge. I understand that Q� �y��✓ v n any pemtit(s)or ATC(s)issued hereatler:re subject to suspension or revocation if the site is altered,the intended use changes,or if as\1 the information submitted in this applicat m is falsified or changed I hereby grant right of entry to the Authorized Representative Q(��\'j, of the Davie County Health Department to conduct necessary inspections to de-ermine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of liroperty lines and corners and locating and flagging or staking the house/facility location,proposed well location and the location or any other amenities. AA 1) M e)c M aQ Site Revisit Charge ro rty owner's or owner's legal representati signature Date(s)a Client _ Client Notification Date: Date EHS: Sign given OYes ONo Account# Revised 11/06 Invoice# Map Output Page 1 of 1 t yt Davie Coun GIS Online Legend [� sabered FezWn3s �� aweaays aeaela NINtSIRTFWWP ✓ MTJiTE �/ WOJC �� RESf PPFA Fmpeny 0.nensi.�ns ED Fmpodrunea Aenel Pholos F odZ os ZOIE] El ..m IM ZO EF R EJz Ex ZC ExL Streams wam.fades I , http://mapsco.davie.nc.w/servlet/com.esri.esrimap.Esrimap?ServiceName=davie&ClientVenion=3.1&Form=True&Encode=False 11/23/2006 DAVIE COUNTY HEALTH DEPARTMENT • Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003585 Tax PIN/EH#: 5832-21-4019-#2 (system) * Billed To: Mariana Maldjian Subdivision Info: Reference Name: Location/Address: 1803 Cana Road-27028 Proposed Facility: Residence Property Size: 6.3 Acres Date Evaluated: Water Supply: On-Site Well V Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope% --L_ HORIZON I DEPTH - to b - — 0 -71 — Texture groupL L G L Consistence �. Structure Mineralogy K1 p HORIZON II DEPTH qcK 0-14 _ ) . Texture group LL �-- Consistence Structure 1_ k 1 h an to V �} Mineralogy1 �, HORIZON III DEPTH "Oil look Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE .a O`•1 SITE CLASSIFICATION: EVALUATION BY: lel 1(/Cr 11t,/I S LONG-TERM ACCEPTANCE RATE: (/ o� 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 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 3�'eI 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 MineraloQv - 1:1,2:1,Mixed ]motes - 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) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003585 Tax PIN/EH#: 5832ZT-4M Billed To: Mariana Maldiian Subdivision Info: Reference Name: Location/Address: 1803 Cana Road-27028 Proposed Facility: Residence Property Size: 6.3 acres Date Evaluated: '" Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ✓/ Cut FACTORS 1 2 3 4 5 6 7 Landscape position b. 4- Slope% ' HORIZON I DEPTH — 6 Texture group C Consistence \1P !i Structure Mineralogy HORIZON II DEPTH Texture group Consistence V Structure ,-I cr, Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence S tructure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE q — 45— Yd-7. CLASSIFICATION LONG-TERM ACCEPTANCE RATE ,, 44 �t SITE CLASSIFICATION: S-�� EVALUATION BY: n\0 J J QJ itd t-1 LONG-TERM ACCEPTANCE RATE: y OTHER(S)PRESENT- REMARKS: LEGEND ndsc pe 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 3�et 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 05/05 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boz 848/210 Hospital Street '�_,_,_�.. ..• Mock"le,NC 27028 4�v (336)751-8760IMPROVEMENT/OPERATION PERMIT Account M 990003585 Tax PIN/EH#: 5832-21-4019 Billed To: Mariana Maldjian Subdivision Info: Reference Name: Location/Address: 1803 Cana Road-27028 Proposed Facility Residence Property Size: 6.3 acres ATC Number: 4066 **NOTE**This 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 Specification: Building Type #People ` #Bedrooms (O #Baths -S;S,�- Dishwasher: Garbage Disposal: E!r' Washing Machine: Lr Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size 6,,SRe Type Water Supplyo4WII Design Wastewater Flow(GPD) 7'2 Site: New 0'*"Repair❑ System Specifications: Tank SizeAWGAL. Pump Tankod?j GAL. Trench Width 407011ock•Depth 42 Linear Ft.200 Other: 0,4 aq/Ouit / As stated in 15A NCAC 18Aj9(5) Required Site Modifications/Conditions: accepted Systems may Iso bo used IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTEIC RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:330 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of ins one#is(336)751-8760.**** C ys11110Z117�Ae �rn '0 Ch � • b � W� 17 Environmental Health Specialist's Signature: / Date: DCHD 05/99(Revised) • DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 G 0 (336)751-8760 Account #: 990003585 Tax PIN/EH#: 5832-21-4019 Billed To: Mariana Maldjian Subdivision Info: Reference Name: Location/Address: 1803 Cana Road-2702 / Proposed Facility Residence Property Size: 6.3 acres ll ATC Number: 4066 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 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specia . 's Signature: Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation 7Permit L 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 tak as a guarantee that the system will function satisfactorily for any given period of time. I \ d, RIN1W - j A G � �- Septic System Installed By0',1 o Environmental Health Specialist's Signature: Date: DCHD 05/99(Revised) r � P R SITE EVALUATION/IMPROVEMENT PERMIT & ATC Q Davie County Health Department �. 1 2 Environmental Health Section I . S Sal G� P.O.Box 848/210 Hospital Street Mocksville,NC 27028 1cN`t�Ro at �pUM'11 pp�l1E (336)751-8760/Fax(336)751-8786 A p ication For: 0/Site Evaluation/Improvement Permit ❑ Authorization.To Construct(ATC) ❑ Both ***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 Ck'n a \.(>, c�� Contact Person W%4n1ay-0, o, Billing Address 1 `P�._ Home Phone 3ln- O - i`L1T� City/State/ZIP nc Sv��\P . NC_ �`Zo2- Business Phone 33(0 - ago -Y l l:] Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey*plat or site plan must accompany this application. (Permit is valid for 60 months with site plan,no expiration with complete plat.) Street Address—IS/OS Qaho�, 12��A City �J\CUC_"C_S vk\\2 Tax PIN#_ 'a_? — 2440 )C' Subdivision Name_ t,31 Pr Section/Lot# 0 Lot Size Directions To Site:(exp) e-,O, ncX_s�,� ON L,—V Date House/Facility Corners Flagged<�),,.k 2_1s 20CSC° If the answer to any of the following questions is es",supporting documerytation must be attached. Are there any existing wastewater systems on the site? Wes ❑No Does the site contain jurisdictional wetlands? ❑Yes Cz&o Are there any easements or right-of-ways on the site? ❑Yes IiWo Is the site subject to approval by another public agency? ❑Yes [�No Will wastewater-other than domestic sewage be generated? ❑Yes VNo IF RESIDENCE FILL OUT THE BOX BELO 1 AVItQ. Id In4lA ouse+ #People 141 #Bedrooms _c'9., #Bathrgoms 62— Garden Tub/Whirlpool &fres ❑No Basement: ❑Yes &go Basement Plumbing: ❑Yes 94c, 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: 9 onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑New Well 5 xisting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U40 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 understand that I am responsible for all charges incurred from this application. 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 on the above described property located in Davie County and owned by_0 2r V�._,vt loll— %kP1\Ck7S Site Revisit-.Charge Property owner's or owner's legal repre entative signature Date(s): Client Notification Date: Date A ^ EHS: Sign given ❑YesB'4/ Account# Revised 2/06 �Q Invoice# uvvm wunty,moan L,aronna �,paaai uata explorer Pagel ot'2 .I ' O S£)alial Data£Z£71t"')rer ®®® C1 4 North Carolina M Click on the Map to: Map Layers ()Zaomin GZoomOut ORecenter Map C1lldemify .Parcels Draw Layers Zoon Factory :'id'. �%Radius search(feet) 0 Drew selected layers: Boundary NW :E ❑Census Tracts City Boundaries" ❑County Zoning .: Multi Symbol El 8111 Fire Districts Q Flood Panels Q Flood Zones Q Parcel. ❑school Districts . ...._........ .. Multi Symbol -i ❑Soil. ❑Town Zoning ❑Tawnships Multi Symbol ❑Voting Precincts Infrastructure ❑V Drlvmays E]Rall Lines HStmetcentarunes ❑USINC Highways Multi Symbol SVJ C SE EV]Aarial Photography ysical Parcel Data n yE —A y Creaks and Riven Find Adjoining Parcels Sent Addresses" • Land until Type:62.91 JAC __J rim Departments County 0. 30 • Account Number. 0000 • Deed Book/Page:00169/0108 ❑Schaal. • Acrounr NumbecD400000030 • Deed Date:1993108122 Draw Layers • PIN:5932214019 • Sales Price:$96,000.00 • Legal 1:62.61 AC CAM ROAD • Property Address: MAP C=gncy 001803 001803 RD • Omer Name:THOMAS RAV J • County Zoning:R-A This map is prepared for the • Owner/Address 1:THOMAS RAY J • Census Code: Inventory of real property lei • Owner/Address 2:1803 CANA ROAD • City Code: inhin this jurisdiction.and l: • Owne4Address 3: compiled from recordeddee • Fire District plats,and other public recor • CilgSlale Zip:MOCKSVILLE,NC 2-T029 • Flood Zane:ZONE% entl data.Usere of this map hereby notified that the • Land Value:$289,550.00 • Flood Community:370308 aforementioned public prim: • Building Value:$191,340 00information sources should i • Flood Panel:0025 C consulted for verification oft • Out Sullding/Erlm Features Value:$23,340.00 • Flood Map Dale:12-17-1993 mbrmation contained on Ni • Assessed Value:$494,230.00map.The Davie County, • Soil:MsD mapping,and soibrrare • Pmoerly Record Cardcompanies assume no legal • Township:FARMINGTON responsibility for the lnforme • Town Zoning: contained on this map or In 111g9F P�Reos D' I i w)wr WINITY MAP I 1 . � 1 ALAN LAMM \ ti 9.B_ 117. PC. 402 �• ARfA- :5.890.AC. 1 ; � \I R ARTHUR J. A/PCASHi,V Jr. D.B. I47. PC. 25 s X 4!tEA» 14.984 AC, /'( v13fY� Nor+Olt PORYCRLY `';If' ..a..vTv.wrw Ym.ww u'S77r4 LD . TRr m nnn:nTc r PJTT 107 M.)AN%k1S ,Sr. I t• mists wc.sVut Tc .+0.s JURY PC. It/ (1b)»I-5616 I69. r !1 Tur d wl.G.rv. RAY J. THOMAS .�+TrTMc•G.11»:,Y w, x.�r,n•rJn) 1)4 rN,K ��.T,p 1i1 A.b1 Nt Opu•T.,vM Gw�MM • TV IG.P ItErt D-J.PARCEL b 7_m-4 l z Ms ~~ Msu s MsD MsD MsD , - MsD sD , MsD MsD MsD MsD MrB2 'Lid AJI'6 SITE EVALUATION/IMPROVEMENT PERMIT & AT Davie County Health Department D 006 Environmental Health Section Aub l 1 2 P.O.Box 848/210 Hospital Street Mocksville,NC 27028 �� 5 Rp1A14� (336)751-8760/Fax (336)751-8786 A or: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) CLBoth Iv( J6 ***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 BillexQ,r\q b �o�\c�\1UY� Contact Person V kayY o�`nA +AaM\1Gtr\ Billing Address Home Phone X3(0 - 4o - S5 1, City/State/ZIP Z vi\\F . NC -9--10 Business Phone 3-,-ko 9 4o Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan,no expiration with complete px plat.) Street Address i O.? (0 „ c� . City- v A \ TaPIN#S q 3 2- �2-yon Subdivision Name $J/jA Section/Lot# 0 of Size (e hf:e, Directions To Site:S00 Cao rw Ah au h �;,� Sr\� QCA%-T 5- Date House/Facility Corners Flagged - g oo(o If the answer to any of the following questions is es",supporting docume9tation must be attached. Are there any existing wastewater systems on the site? D'i'es ❑ o Does the site contain jurisdictional wetlands? ❑Yes NZN Are there any easements or right-of-ways on the site? ❑Yes go Is the site subject to approval by another public agency? ❑Yes Will wastewater other than domestic sewage be generated? ❑Yes IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms LP Bathrooms s 1/2- Garden Tub/Whirlpool EW8 ❑No _ Basement: FZKes ❑No Basement Plumbing: es ❑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: :l#Seats Type system requested: [IirConventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑ New Well i 6isting Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 14 o If yes,what type? This is to certify that the information provided on this application is true and convect 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 understand that I am responsible for all charges incurred from this application. 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 on the above described property located in Davie County and owned by Jas �r�� Mgv1A �11a\dL�� \ Site Revisit Charge Property owner's or owner's legal represehiative signature Date(s): Client Notification Date: Date 0 EHS: Sign given ❑Yes ❑No Account# Revised 2/06 Invoice# U>zv`iC wunty, ivortn uaroiina bpatiai uata P_xpiorer Page 1 of 2 -alta/ Data lk-:?) er Norah Carolina Click on the Map to: Map Layers Q Zoomin I ZoomOut 0 Recenter Map Cad Identify :Parcels ` I Draw Layers Zoom Factor: 2X Draw selected layers: U Radius Search(feet),0 I Boundary N%1V NE [:]Census Tracts tr w� 8r�. ' , *r h_ r Y rE ' , s J� r� ' City Boundaries.. ` P, a M.u..,+¢ q �'iF�£P 'x E]County Zoning 1 i 3{'f's.sir p�'�,c '� k}�Sz :- lr.+'l , 5s s .'s h:T,' .E f,: N` �•£Yr�1 '�tfi s .ry�� r� }�k�"i'r Multi Symbol Spy p{:=epi st � '3wrSl. 1 { r L 7�r,}ata'�r E911 Fire Districts Q Flood Panels s . Y k+o wp, X� �-' �7 $ ° i44'��yul,Y'"''•�. x ,('rt� .. �y1tit� rµ, �,1a QFlood Zones . ,�'{{ i� ( k Parcels , .y} -R 's ��tr�j'�'dE v'tfT� School Districts i� ya y fy�} _------ �l Symbol mbol 3 ,, q �r w,� i iksr, a i , �,w � �•� � r ��Y' <.?st J �syS- . t } !t t y t A!1,1* ",y '•t t1' .. ............... ....._.. _ *A+ " �•' is'�.Y tt �.w ., r ,t' ,•s s '�¢ Solis .,,. fi�n� � r�4e• � �, f�'�� t ...,��..�F��ppt =ti ,�r, �;�, t "" '.� Q Town Zoning 3ja.nsr To._w._..n._s_h_i_p--s R -. ....._.. Multi Symbol ' __. ......., 3�^z l . R gg 7Y« .i�s"w� n Y.c +F r..i ua+`utk� �+ +�S�ei� r{'t. Voting Precincts t" s Wkt's 9` tr 7<z FNr, {,f >flT ma a t t E .' eF � �># � �� infrastructure a .'+, "A � t ;�� F%/]Driveways PP{ Y � � �`+C'faII}`7'L`;.!�'��Il�a>i'$1.Ga/7_•}.'jil[`t'',f�.�'f�'+;tn�V�.At'..je'5Sc.?',Y}`�/,},�q�.+.,a::.r�.�%`f;1'�'jFd�.vx�'5v�,xLYs S,,�}A,f ly.'rtrfitl?�w j?�={�u�}.X�t�1.*k+�r,i.+'n{1�4,t`�t?3.}F,f•+af,�rip�.�+!rui�,}1�"y`+}fP,`1�rth,sP,d'.�1§i<t{:"4,J,��°:"5"{itrt�t'�t,tyf�'�+fti}r.�c yr3"�d•-+r3r,��rssR�v�'i4f�4F6�Ts�vr{,~fF{.��'.-:,�a�I„�swr9,��ra,�#�e`i.I4.f.�ret},s"}p.�E�t.1�vYstS4i,y��t��„1�r tr!.�K'�S}Y 4'°t:� t �d E]Rail Lin es Street Centerlines terline s 0 US/NCHighways St4:w Multi Symbol SW , S[ /� Q Aerial Photography � ' \V_ o`/ on � R” hysical Creeks Parcel Data —01”` � Creeks and Rivers Find.._Adjoining-Parcels ,� �`� � E911 Addresses•• • Land Unit Type:62.81 :/AC F]Fire Departments • County 10:D400000030 • Deed Book/Page:00169/0108 Schools • Account Number.D400000030 • Deed Date:1993/06/22 Draw Layers • PIN:5832214019 • Sales Price:$96,000.00 • Property address: MAP Currency • Legal 1:62.81 AC CANA ROAD 001803 001803 RD • Owner Name:THOMAS RAY J • County Zoning:R-A • Owner/Address 1:THOMAS RAY J This map is prepared for the • Census Code: inventory of real property foi • Owner/Address 2:1803 CANA ROAD • City Code: within this jurisdiction,and r: • Owner/Address 3: compiled from recorded dee • Fire District: plats,and other public recor • City,State Zip:MOCKSVILLE,NC 2-7028 • Flood Zone:ZONE X and data.Users of this map hereby notified that the • Land Value:$289,550.00 • Flood Community:370308 aforementioned public prima • Building Value:$181,340.00 information sources should I • Flood Panel:0025 C consulted for verification of 1 • Out Building/Extra Features Value:$23,340.00 • Flood Map Date:12-17-1993 Information contained on thl • Assessed Value:$494,230.00 map.The Davie County, • Soil:MsD mapping,and software • Property Record Card • Township:FARMINGTON companies assume no legal responsibility for the informs • Town Zoning: contained on this map or in 11++x.-1144 -)no 1InA1CA/.-..---.1 0i'•/._.1 r11_n7 .r. + rnnnAn AinnnA i Nay r �t�g6 NAN to 6`pt. D ) w swr I 1YCINITF 1KAP i f f ALAN uTR,x D.S. 147. PC. +01 �• AREAS :5.830.AF. \ r � r � ARTH[!R J. MrCASHI11 Jr. D.B. 747. PC. 15 yy 'l �� v 1.VIM; .l�." .a. L"i X044 AQ .. 131 'or 04 PORJfzRzr D04PORyLRzr I•!STlR L•f TOA' f T1R ftt 6V7n".G MUPArt f 707 M'MIM SKISIVW.S7. 6. H1N6S .loc.s+ut 77c o:S WAY PG. W 1176)751-5616 f D.B. 169. . !, f7y77 v 7111.67 7n6 1 RAY J. THOMAS .Cti Y�..'.w.w rr. ...1t pt)77y4'71.wy.f.N N.•�p M 4.�b L - ' ..w..•Ir.4+OMI�:t J...V w. K..p..n•7.M.lA 106.7r,N' 11 W 0011.I.Y..eY.M 7.WlM • - ... lu vlv IK7'1 0-6.rmm 30 J.•O`Ol-1 MsD k MSD , n e MsC .. MsC .I--- MsD MSD MsD , - MsC MsD MsD MsD MsD MrB2 SCC ChA 4 43 _. _.. ....._. ,..�....... ��.�... .... w...a. ww. _�,r�w...«.._.�.._. ._.n..:.ax.r�.... u.n x..w.-n»a. ... ..a�x..aVY DAME COUNTY HEALTH DEPARTMENT Environmental Health Section . P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003585 Tax PIN/EH M 5832-21-4019 Billed To: Mariana Maldjian Subdivision Info: Reference Name: Location/Address: 1803 Cana Road-27028 Proposed Facility Residence Property Size: 6.3 acres ATC Number: 4066 **NOTE**This 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 SiITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. 1 Residential Specification: Building Type #People_ #Bedrooms 4/ #Baths Dishwasher:0 Garbage Disposal: ❑ Washing Machine:, Basement w/Plumbing:0' Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrrial Waste: A ❑ Lot Size Type Water Supply Design Wastewater Flow(GPD) L66 Site: New.2alRepair❑ . System Specifications: Tank SizeJ,�GAL. Pump Tank/P&GAL. Trench Width_(?/,"Rock Depth JV'� Lmear Ft.;!� Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie Co un I D ent 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 da st elephone#is(336)751-8760.**** Co G)yi GcJ�I/ Y Environmental Health Specialist's Signature: Dater DCHD 05/99(Revised) c r r lJ't�96. J'Ds'. ." D 1 I viru T}' MAP .1 r I ALAN LAMM D.B_ 147• PC. 402 � AR1'A� ;S.J�o.AC• 1 f `I ABTN(IB J. A(rASH1N Jt. D.B. 149. PC. 25 • f S `Joe�'YANDlR •'�".d..+`_.. A:�• ..l• - 'u1 i li.'.i: rv. .3rTr G• JII JCA S_YQQQ A� 3" t � AREA- 0I.,984 AC, _E 1 �� , ,•\ /o'iM.�<Hca..• :•i.• cs Nor OR r LfSTlAP�.�AA•TO ' Ttil}ippf fI1f. n"C$"ft w.$l.t0$1. lo.u0frn rlsw . ' NARY 6 HINd„1 wc.swe 1.a1 D•8• 169. � 11x))7 tel-esu !I I RAY J. THOMAS {'ti/t'_Nw MswN..11t Of J•11/L�f Iln y�«N p IMI IY./11dM{ ' • ..wwauG KM..:Z J.JV•IWw.•M.Npn,n1•f,/lyll IY�.•/..K y/K MK•s ILnui� Ibc w►RV:p-a,F;ARm so 1.+oosd cavTe wunty, ivortn t-aroima'bpatiai Lata hxpiorer Page 1 of t O Nim l _ • lige/ Da [ p1��r�' Norh Carolina Click on the Map to: Map Layers ................. ._.._.......... ._ 0 Zoomin 0 ZoomOut 0 Recenter Map (�?�Identify Parcels ..ryll DfaW Layers !. Draw selected layers: Zoom Factor. 2X Radius Search(feet):0 1 Boundary } Q¢}� 0 Census Tracts V?r City Boundaries.. ❑County Zoning �,b r Multi Symbol #�.n . l; r,�•d R` .r ?' A? y b.. I Y 1 f +r't' � 'F'��?' '�'�.ky&'� ,'J __ _--'--....-._ -...---_. .... E911 Fire Districts t r r Q Flood Panels �� ., �S+�m ,5 �z+.�" �+'��✓p;r f' ��t� �•h�fi .•:a� x� � � Flood Zones `ha y"4 ?� gw 1 *.�.... '•* i ,: r 3 , ., rtt�'x i ' ¢. V❑Parcels E] kif 44 , •'`y�`vet.4 ci �a,ys Sti £,+ �' g *+ a �.,'T fi 4 bt �`�'. .H« School Districts t ?facts ---......-_.....__ w Multi Symbol iiir � e L SoiIS Town Zoning tn Townships Multi Symbol mbol Y w E]Voting Precincts Infrastructure aY+'cl�RKtryfW'r '". k a its nV Driveways {w, , ❑Rail Lines .' i° a `f`'it a Y �..+• L + t �t�'eii� r� t+SgJwfi 7t. ❑V street Centerlines ryFr� "y7n+t is?fir `14na , R ❑US/NC Highways Multi Symbol SW L 19S Q Aerial Photography 41 Parcel Data `n �,, hysical V Creeks and Rivers Find._Adjoning,Parcels � e�''- � E911 Addresses•• • Land Unit/Type:62.81 :/AC 0 Fire Departments • County ID:D400000030 • Deed Book/Page:00169 10108 Q Schools • Account Number.D400000030 • Deed Date:1993/06/22 f Draw Layers • PIN:5832214019 • Sales Price:$96,000.00 • Legal 1:62.81 AC CANA ROAD • Property Address: MAP CUrrengy 001803 001803 RD • Owner Name:THOMAS RAY J • County Zoning:R-A • Owner/Address 1:THOMAS RAY J This map is prepared for the • Census Code: inventory of real property foi • Owner/Address 2:1803 CANA ROAD • City Code: within this jurisdiction,and is • Owner/Address 3: compiled from recorded dee •-Fire District plats,and other public recor • City,State Zip:MOCKSVILLE,NC 2-7028 • Flood Zone:ZONE X and data.Users of this map hereby notified that the • Land Value:$289,550.00 • Flood Community.370308 aforementioned public prime • Building Value:$181,340.00 information sources should I • Flood Panel:0025 C consulted for verification of 1 • Out Building(Extra Features Value:$23,340.00 • Flood Map Date:12-17-1993 information contained on thi • Assessed Value:$494,230.00 map.The Davie County, • Soil.MsD mapping,and software • Property Record Card • Township:FARMINGTON companies assume no legal responsibility for the informa • Town Zoning: contained on this map or in „� littp:H66.208.132.254/servlet/com.esri.esrimap.Esrimap?Name=Davie&Cmd=Clk&Left=1530248.... 4/10/2004 APPLICATION FOR SITE EVALUATION/IAIPROVFAIFM OF-11 Davie County Health Department Environmental Healf i Section �e P.O. Box 848/210 Hospital Stre t /Q Mocksville, NC 27028 (336)751-8760 ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL INFORMATION IS`` ' `PROVIDED. Refer to the INFORMATION BULLETIN for inst ti ns. 1. Name to be BilledM irtOrka -kckt&�layN Contact Person A�1�Q✓\A ` Mailing Address r6LIca \`CQ, Home Phone e2,��o CJC'0 —'-q l City/State/ZIP 1.11 or_te,-y f— x"10 Tr Business Phone 3 (o- Q 40 591`1 2. Name on Permit/ATC if•Different than Above Mailing Address City/State/Zip- 3. Application For: M Site Evaluation ❑ Improvement Permit/ATCBoth 4. System to service: VHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: 12 Conventional ❑ conventional modified ❑ innovative ;2 I/2 L� rreH� 3 CGlfCha c1d 6. If Residence: # People _ # Bedrooms vw(sc au -A$ # Bathroomj� f' h° 'f add tai"'k 1 V,5i'hwasher ❑Garbage Disposal 04111,ing Machine Mtasement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes' # Showers # Urinals # Water Coolers IF FOODSERVICE: #1 Seats Estimated Water Usage (gallons per day) 8. Type of water"'supply: ❑ County/City L+3"'We 1l ❑ Community 9. Do you anticipate additions or CxpallSiollS of tile facility this system is intended to serve? SK'cs ❑No If yes,what type?Q_ S Y�-k V-0� 06�P,-A L-K '"� A-0 �Jv\lo� o n1 Y\.-ke w a �-:--- -r- q,,-d 3'/ 10-,fir ***I1IfPORTAN7'***CLIENTS AIUST C0,1fPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED •-- BELOW. Either a PLAT or SITE PLAN AIUST BE-SUBAIITTED by the client with THIS APPLICATION. Property Dimensions:fta-v.t PeZ 0\-,*, (A acre C WRITE DIRECTIONS(from Nlocksvfllc)to PROPERTY: Tax Office PIN: IE -Z i 4inanp, 10 Vievv Property Address: Road Namc ISJS Cgyta V-d &',k- i cI A I urn CC c>y,At eM"Ipot 1 6y-\ City/Zip Modc cy 41e Pu cke'!a ..` 1/k If in a Subdivision provide information,as follows: 'l?) e,Kj .. .......... Section: Block: Lot: Date home corners flagged: y ni Vf W a 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 l aur respor:sible for a!l charges ir:crrrred front this application. I,hereby,give consent to the Authorized Representative of the Pavic County IIealth Department to enter upon above described property located in Davie County and owned by ofge C".4 a,e-\ to conduct all,testing ,procedures as necessary to determine the site suitability. DATE C// Y�X : Z)0:5 SIGNA TRIS 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). 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