574 Childrens Home RdAccount #: 990003828
Billed To: Mark Revels
Reference Name:
ATC Number: 4337
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(33G)751-87G0
Tax PIN/EH #: 5813-73-4677.01
Subdivision Info: Div. Wm.Revels Lot # 01
Location/Address: Childrens Home Rd.-27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MiJST 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 CONSTRU TION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: (��r.3��
CERTIFICATE OF COMPLETION
'**NOTE* * T'he issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
I 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.
Septic System Installed By:
�
� � Y/ i�l�i`.r�
Environmental Health Specialist's Signature : ��1 ��� Date:
DCHD OS/99 (Revised)
�, ' • ' DAVIE COUNTY HEALTH DEPARTMENT
.� = , Environmental Health Section
� P. O. Boz 848/210 H�pital Street
. ' Mocksville, NC 27028
(336)751-87C►0
Account #: 990003828
Billed To: Mark Revels
Reference Name:
Proposed Facility: Residence
IMPROVEMENT/OPERATION PERMIT
Tax PIN/EH #: 5813-73-4677.01
Subdivision Info: Div. Wm.Revels Lot # 01
Location/Address: Childrens Home Rd.-27028
Property Size: see map
**NO"CE�*-Th�is�mpro4ement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An AiJTHORIZATION 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 � #Baths �
Dishwasher� Garbage Disposal� Washing Machine� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 0
Lot Size Type Water Supply (il/ f�l Design Wastewater Flow (GPD) _C�� Site: New��epair ❑
System Specifications: Tank Sizelll"i"b GAL. Pump Tank GAL. Trench Width � Rock Depth��/JLinear Ft.��D
Other:
As stated in 15A NCAC 18A.1969(5)
Required Site Modifications/Conditions: accepted Systems may also be used
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6" BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
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 (33G)751-87G0.****
�
;
Environmental Health Specialist's Signature: v Date: ��/� 6
DCHD OS/99 (Revised)
.'
APPLICATIUN FOfi SlTC CVALUATION/1hIP(iOVL•hfCNT I'LR��f17 � A7C
� ; Davie County Health Department
En vironmenfa/ Hea/t/� Seciion
P.O. Box 848/210 Hospital Street
' Mocksvilla, NC 27028
C �' (336) 751-0760
�� 1� �'�
C�� � ��'
� �
3�p�' I
�.
***I�IPORTANT* ** TIiIS APPLICATION CANNOT 11� PROCESSED UNL�SS ALL TiiE RLQUIRED
INFORt•Jl1TION IS PROVIDLD. Refer to the TPiFOR2dATI0N BULLETIN for inuEructiona.
n_ 7 c�
1. t7amc to be Ailled ��� A, �L �. �� Contact Peruon �0 t�C /�. r JTd��=
Y
1•failin� Jlddrosa _ I� S L� � J� V �Z� �4fJ L Ifomo Ptiono ��
City/3tato/ZIP ►r t OGI�sV � l.L�' , �v � 2%� Zp IIu�inenn Phono ��� � y,�� �����
2. 2tama on Pezmit/11TC if Differant than 1►bova j,/y �� � S !9 'il C V�
Mailin� Addroas City/Stato/Zip
3. Application For: ytl Sitc �valuation L� Improi�'eme�tOl�ermiL'/ATC ❑ Doth
4. syfltcu� �o survice: li0 Iiouaa ❑ 22obilc Homo ❑ DuBine3Q ❑ Induatry ❑ OL-her
5. Typn n}•ot•em requo�tad: �Conventional ❑ convontional modified ❑ innovativo pacCepted
6. If •Ito�idenca: It People f1 IIedrooms �_ il BaLhrooina z
7.
NJDi�liwa�hor ❑Carbago Diapo�al tln9ashing t2achina
Ii Du�inean/Induatry /oehor: verify type
II Commodoa
II Showorn
IF FOOD�ERVICE: �� Seata
�Dasement/P1unS�ing ❑Danement/210 Plumbing
t1 Urinaln
# People 1! Sinku
i! 1•]aCor Cooloro
�sEimated Water Uaage (gaiion� per day)
n. T�a ot wator aupply: ❑ County/City ❑ Well O Community
9. no � on auticipato addition� or cxpansions of thc facili(y tliis s}�stcm is intcudcd to scrvc? ❑ 1'cs ❑ No
If ��cs, n•hat typc?
***I1IIPORT'�INT'`** CLILNTSh1USTCOAlYL�7li'TII� ItL•QUIRED PROPCRTY 1NI�ORA�IA'I'lON I2I:QULSTGD
Itl;t.O1V. Iiitl�cr a PI.AT orSITC PLAN rlIU.ST IlLsui�arrrrr:n i�v tl�c clicnt with'CIIIS API'I,ICATiON.
P►•opert��llii►ici�sio►is: Sc'C ATTACr�� ��L��'
•ra� O[Gcc PIN: i� 5 t� i 3�1 3y �� �
I'roperl}'Adclress: RoadN:imc CNIt,Q,26NS H�r�1� J2fl
t�A k i Q h'� k l.uT 2
'j1�'�. �M � G' 3 Citylzip I�1 o c l C S�f � c.l,� � IJ t
- 27�2 i�
If iri a Subdi��isioli providc iiifoc•cualioli, as follotivs:
L.a-r �, - 1�+�I �5,0� 01�
Namc: �(.UA� ���=��c C$ �'ui�� �17�/1
�
Scclioi�: Bloclt: Lot:
1VI�1T� DIRCCTIOn'S (1'rau 11-Iodtsvilic) ta P1t01'LK'I'1':'
11 S f—� W`( �� � /�o Yl '! !-� �
r
-�,� �+� c� � � ��� N �z�� : � L�:r-T
� N CN I r� f�va�a+,� �v �+�0 �
G►�f i �� 2�=�1.5 �vm�� /�v�% , Lc.�7
, Cr-! � l.(� 2 t�7J .S 1 J a rvt, �" f ,_ � S
p,.�1S�% c��ac.� ����✓v1r�7JT Zso'� a►J ,2�S��T
ll:itc 1lomc coriici•s tlaggcd: /"Z • 2 1• 0 5
'I'his is to ccrti!'y tliat tlic informatiou providcd is corrcct to tIic bcst of ury I.noivlcdgc. I uncicrst�ncl tliat any perinit(s)
issucd I�crcaftcr are subjcct to suspcnsiou or rcvocation, if tlic sitc Plans or intci�dcd usc ct�au�c, or iC tl�c iuformalion
submil(ccl iu (liis applic�tiun is f:�lsilicd or cltangcd. I, al.so, rrndcrstrurr! Ihat I aur respolrsiLlc fi�r nl! cicu�b�cs incru•r•crl fruu!
11ris applicnliva. I, I�crcby, �;ivc conscnt to tl�c Autl�orizcd Rcprescntatiti�c of thc Davic Couuly IIcaltli llcparttncnt
to ciitcr upo�i abovc dcscribcd pro��cc�ty ]ocalcJ iii ll�vic Couiit�� at�d o`ti�nccl.by
to concluct :ill tcsling proccdiu•cs as uccessar}• lo dctcrmiuc tlic sitc suit:�bilif��.
D�l'I'I? � Z� ��� � S SIGNA'I'URI;
TIIIS AItLA RIAY BI; USLD rOR DItA1VING YOUR SIT� PLAN (Iucludc all of ll�c follotiring: L�is[ing �ud proposcd
property lincs ancl dimcnsions, structures, scWzcics, and scptic locations),�� �
� / _ .�'''��'
Sigt� givct�
Reviscc] llCIID (05/03
f.� N-�•. �'!✓�— {..a FR°r�7
F.�,.� �.'�" %-�%'. S �—° "�` \
D:ttc(s): �
Clicnt Notification Datc:
�I-IS:
,�tccount Na � �
I�iti�oicc No. � O
I, G�or • Rob�rt Ston�, c�rti}y ihat thls pfat raa drarn und�r my I, Surveyor, aatHy STATE OF NORIIi CARQUNA - F�I�d tor r�Qisiration at o'clock M
p Gsorqs Rabxt Stcne.Prota�loral t.and L-3te2 to one Childrons Home Rd
sup�rvislon trom an actual surv�y mod� und�r my sup�rvislon (d��d d�seriptlon ofthsfoibiringa�tndieatedMw, � or �- CpUNTY OF DAVIE
reeore�d �n Book -�, PaQa �, ete.) (otner): tAot ths bounaar�ea not , 2o and r�cord�d Chinquapin Rd SR 1328
surv�y�d ors elear Ir Indleat�d as drorn from Informaf lon found In Book . � a. That tlib plat b of a r�rwy thot enat�a ribdNMion of land rithin
Pap• ' that th• ratlo ot pr�olalon cs caleulat�d Is Ii10,000: that thls tM arsa of a eounty or mwdeipatlly that has an ordinanu that To US NWY 601--►
plat ras pr�pared In aecordonc• wlih 6.3. 4T-30 as omended. Witness my orlpinoi �y��Mparoallofbrd; �, John Gallimoro, Review Officer of Dovie COtJt1{y
siona�ur•, r�plstratlon numn•r ona ,•ai cert that tha map or plat to which this certificatwn �n ria� eook , vap• .
2� December 2���J ❑ b. Tha!thh plat b d a wrvey that is bwbd In such portbn of a 18 �X� meeta all stotutory roquirements for recording. �,�. Brent SAoot, R�ylst�r oi D�eda
t h I s day of , A.D. . eounty or munkipaMy that h unngulatW a�to on ordlnanu
* RB 319 A PG 554 t�1O�f°9°�"PO"O�'°�1ond' F I I I nQ Fee Pa i a Childrens Home Rd
S e a I o r S t amp George R. Stone � o. nwt tnt�vbc is of a survey of an exts�irq paRe�a��ea Review Oificer.
SR 1329
�r b�d, Date•
9urv�yor �
�N CARO � d. That thN pla!M of a wrwy ot anoth�r eobqory.weh os ths Dy DEPUTI�—AS313TANT • Lot 1
� ..,.._..,, � � 'OL�O1T�1O�b"°F O10'd"9°O1�''°�-ordsrad"110�'°f°�1°` "NO APPROVAL REQUIRED B^l THE COUMY PLANNING DEPARTMENT' �
� SS ,1� � s �xe�ption W ths dsflnitlon of aubdM�bnt Lot 2 s
i
2�Q���E /O"�'q� � s. That tM Infomadon avaBabN to thi�wrwyor I�weh that I am 1\
SEAL Y ������a���+m�•��mr w��� John Gallimore, Planning Diroctor �
T FOR RECORDATION, a���������co���cn o�•• �
�;r L-3162 i EEDS, OR BUILDING pate ��
� '�y� � O George R. Stone
�
�G��:••S�R R.5 COURSE BEARING DISTANCE vcinity Map � )
P�or...io�o���a s��«,�-aisz Not to Scale
ROBE
• The conveyance of a lot or tract for the purpose L-1 S 25°24'36"E 37.87'
of dividing land between persons related among the L-2 S 29°34'13"E 31.92' I heroby certiry that the Davie County Health
third degree lineal kinship. L-3 S 34°16'08"E 77.41'
L-4 S 37°45'35"E 74.20' Department hcs evaluated the Subdivision
L-5 N 10°17'17"W 100.00'
Tax Lot 2 entitled with
Tax Map C-3
n/f �Iliam Junior Revels respect to criteria and conditiona estoblished
Re 338 � RB 319 O PG 554
pC ' by state law or promulgated thereunder and thb
15 same ie found to comply with auch criteria and
/ __� conditiona D(CEPT as found in auch evaluation.
x
324��p' / �� For details of this evaluation and for limitations
S 25°14'41"E y S 70°02'41"W
,�� � 47.99' see the written report on file at the said
� IRS
x/ Department.
� ��
/2 EIR Fnd
Tax Lot 23 X/ IMPORTMtT NOTICE:
Tax Map B-3 /X� THIS CEI7TIFlCATE DOES NOT CONSTITUTE A PERMIT OR
n/f Jimmy Revels
Ma S CRevels / �x ,5g"W 2�?6p, Te APPROVAL OF INDMDUAL LOTS IN SAID SUBDMSION
DB 87 A PG 264 X/x , N ���� M���°2�Qne Tax Map C-3 FOR INSTALLATION oF SEWAGE FACILITIES
/ x�� 24�2� \S°£ n/f wlliam Junior Revels
o-X R8 319 O PG 554
�x 1/2" EIR Fnd
:-
/ Tax Lot 2 v�° '/z'Q F"°
Tax Ma C-3 0�° LOt 2 '�' Date County, Heolth Official
n/f William Junior Revels ~N Part of Tax Lot 2 $
RB 319 O PG 554 W Tax Map C-3 � � I
�
� 1.000 Ac +/- 3 � �
Tax Lot 2.02 $ Tax Lot 2.03
^ o Tax Map C-3 + Tax Map C-3 I Begin Exiating 20' Ecsement (See Note �1)
ti T� M N n/f Tonya Revels � n/f Cha�les Tatum ..-
/ S p?,SLn� Z M RB 338 A PG 175 and wife /� /
,y 4 p4,� � Leatrice R. Tatum I �
N '1 /�
w 3p)38 �
ti R/W '�� ���°°a�.
` °�� I 5k���
� �� � ��/;,
�p/ �/z•ae�a t�u�. �/r t�e F�a �,;=/ ,,��
W \ � r�u�. ws rao.a 1,�3 ,, �'' , "� '
� ���'�� - - ti u�" 2 -� �' IRS
�.�- -��.�-�
��� b N 19'ZTS1"W � �'�.�� ''
I (we) hereby certify that I am (we aro) the owner(a) � � � 01Mc^id . �so.ar �-_���' -=�'
of the property described heroon, which ia lxoted in ` �'S -- ------------�—------=----=- --=� -'/
the aubdivision juriadiction of Davie County and that � .. ___l�_�''
I hereby adopt thia subdiviaion plan with my froe �'� �. _----------_----_----_-----_----_---- "- - )
c�nsen� eatablished minimum building aetboek lines _���� ���,��� I -�c�i� C'`
ond dedicate all stroets, alleys, walke, parka and �----- ---�-� End of Pwement/End of NCDOT R/W dc Maintenance o • ',,�
CJtil drens Home R o ad Begin Existing 20' Easement (See Note �1) °�D �� Lot 1
�o�� and easementn to public or private uae � `� Part of Tax Lot 2 N Tax Lot 2
S.R. 1329 °' TaX Map C-3
° Tax Map C-3 c`rr,
50' Public R�W 20'+�- Pavement � �'' �, n/f William Junior Revels
� � k a �! RB 319 O PG 554
Tax Lot 1 \X � T f 1.000 Ac +/- �
� o•�•(•) Tax Map C-3 �� � S`
Owner: n/f Marisa Scarlstt n� -+
D B 1 2 6 O P G 6 7 2 N Q
William Junior Revels o�
135 Leisure Lone
Mocksvilie, NC 27028
3
���9.
H�s°�
R/W - Right-of-Way �N� FC - Face of Curb \��.
EIP - Exiating Iron Pipe BoC - Back of Curb
EIR - Exiating Iron Rebar PP - Power Pole TUX LOt 2 �,
P - Poat LP - Light Pole Tax Map C-3
CM - Concrete Monument MH - Man Hole P R E LI M I N A RY Division o f the: n/f �Iliam Junior Revels
IRS - Iron Rebar Set CH - Chord Diatance .{-
P/L - P�perty Line P/0 - Part of RB 319 O PG 554 \
C/A- Controlled�ceaa DB - Deed Book Wil liam J. R ev e ls
CP - Concrote Pi PB - Plat Book ,�.
CMP - Corrugated Metal PiPe RB - Record Book NOT FOR RECORDATION�
CPP_Corrugated Ploetic P�� Pc - Pase DEEDS, OR BUILDING Pro�erty \ ��
-F- 100 Year Flood Boundary CB - Catch Basin ,r
-0- Overhead Utilities -S- Sewer Line
-X- Fsnce WM - Water Meter \
Fnd - Found wv- watx vawe Part of Tax Lot 2, Tax Map C-3,
n/f - Now or Forma�y BM - Bench Mark Record Book 319 � Page 554 �
NMP - Nonmonumented Point TBM -Temporary Bench Mork Total Area Lot 1: 1.000 Acres -� - b coordinate COrI'1 UtOtlOf1
CL - Center Line RRS - Rail Road Spike � y P
EP - Edge of Povement CN- Cable Televieion Pedestal Total Area Lot 2: 1.00Q Acres +/- by coordinate computation k\
TP - Telephone Pedestal Ef6 - Electric Transformer Box SCALE TOWNSHIP Cp�Jp(N STATE QI�TE L M
-W- Water Line CO - Sanitary Sewer Clean Out
1" = 60' Clarksville Davie North Carolina 12-20-2005
NOT FOR RECORDATION.
Stone Land Surve in Com an ,,� No, DEEDS, OR BUILDING
so a so �2o i so 5��: Y 9 P Y
SC,DB,DT George Robart Stone, PLS L-3162 18605
MAPPED: 113 Drum Lane Phone (336) 998-4733 MAP N0.
GRAPHIC SCALE — FEET cRs 7docksville, r,.c. 2�028 isso5
, • . ' • DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil / Site Evaluation
APPLICANT INFORMATION
Account #: 990003828
Billed To: Mark Revels
Reference Name:
Proposed Facility: Residence
�ROPERTY INFORMATION
Tax PIN/EH #: 5813-73-4677.01
Subdivision Info: Div. Wm.Revels Lot # 01
Location/Address: Childrens Home Rd.-2702 /
Property Size: see map Date Evaluated: b�
Water Supply: On-Site Well �" Community
Evaluation By: Auger Boring Pit F✓
HORIZON III DEPTH
TillTir//l1� T<f TTM�T�
�r�rnvi.i i n
SITE CLASSIFICATION: ----�
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
EVALUATION BY:
Public
Cut
Landscape Position
R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope
CC - Concave slope CV - Convex slope T- Tenace FP - Flood plain H- Head slope
T.e�Cturg
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
aZ41S�
VFR - Very friable FR - Friable FI - Firm VFI - Very �rm EFI - Extremely firm
�
NS - Non sticky SS - Slightly sticky S- Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P- Plastic VP - Very plastic
�tI31C�i1L�
SC - Single grain M- Massive CR - Crumb GR - Granulaz ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
MineraloQv
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 - gaUday/ft2 DCHD OS/OS (Revised)
.
; ����� ��������� ��������'
�.... ., � ,.�,ur.r. _,... ..�..w .... .... ..... .. ... �a.�..... a,.� ,_. �., .,.,. ,.�,._ �.... , .... � �.. .
Environmental Heaith Section
P. 0. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville, NC 27028
.. �. n ., w_... .,. a... ., �.r ,
�� .. ., .,,
, ,..�... .. �.., . . � .
�
(336)751-8760 ` `�
s
Decemb�r 28, 2005
Mark A. Revels
135 Leisure Lane
Mocksville, NC 27028
Re: Site Evaluation/ Children's Home Road
Tax Office PIN: #5813-73-4677
Dear Client(s):
As requested, a representative from our office visited the aforementioned site on
December 27, 2005. Based on the information provided on the Application for Site
Evaluation and after an evaluation was completed on the site, it was found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
�d2;�t��/��,.
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RBH/bml