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672 Cornatzer Rd. • � DAVIE COUNTY HEALTH DEPARTMENT � �. � Environmental Health Section Account #: 990003022 Billed To: Thomas Frye Reference Name: Pro osed Facilit Residence � ATC Number: 3644 P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (33G)751-87G0 Tax PIN/EH #: 5758-75-6962 Subdivision Info: Location/Address: Cornatzer Rd-27028 5ize: � acre AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLIED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION FOR WASTEWATER CON TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health SpecialisYs Signature: Date: d � CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit 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: Environmental Health Specialist's Signature : �`Z� / Date: DCHD OS/99 (Revised) . ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Heaith Section ' P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-87C0 Account #: 990003022 Billed To: Thomas Frye Reference Name: Proposed Facility Residence IMPROVEMENT/OPERATION PERMIT fi��t'�-��-d% ��- S � 3 ° �� Tax PIN/EH #: 5758-75-6962 Subdivision Info: Location/Address: Cornatzer Rd-27028 Property Size: 1 acre ATC Number: 3644 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALITHOWZATION 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: � Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �_ Design Wastewater Flow (GPD � Site: Ne�Repair ❑ System Specifications: Tank Size �GAL. Pump Tank GAL. Trench Widttr�� Rock Depth��Linear FtQ�� Other: Required Site Modifications/Conditions: IMPROVEh1ENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF C" BELOW FINISI�ED GRADE. ****NOTICE: Contact a representative of �unty Health Department for final inspection ofthis system between 830 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p on the day�ns��ation. Telephone # is (33C►)751-87G0.**** Environmental Health Specialist's Signature: DCHD OS/99 (Revised) .��',� r�y� � Date: � � V » . APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT Davie County Health Department Environmenta/Hea/th Section P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ��F� �E ` ` �U� t & �� ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS A�Z"TFI� INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instruct � 1. Name to be Billed Mailing Address Contact Person Home Phone � � v � � Z7 � City/State/ZIP �Q[��(f f�f,� �//, `. � �� (�S Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: �Site Evaluation ❑ Improvement Permit/ATC �Both 4. system to service: L�l House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. Type system requested: ❑ Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People _� # Bedrooms � # Bathrooms � N1'Dishwasher ❑ Garbage Disposal OWashing Machine ❑Basement/Plumbing ❑ Hasement/No Plumbing 7. If Busineas/Industry /Other: verify type # Commodea # Showers # Urinals # People # Sinks # Water Coolers IF FOODSERVICE: # Sea Estimated Water Usage (gallons per day) s. Type of water supply: County/City ❑ Well ❑ Community 9. no You anticipate additiona or expansions of the facility this system is intended to serve? 0 Yes B� If yes, what type? ***IMPORTANT*** CLIENTS MUST COI�IPLETE THE REQUIRED PROPERTY INFORMATION REQUCSTGD BELOW. Eitlier a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: �� // 1-� C� �� WRITE DIRECTIONS (from Mocksvilic) to PROPGRTY: Tax OfGcc PIN: # J�s� '�-1� gE�� y�,� t�� (.,D✓/i�T2,�1� �� Property Address: Road Name (ip j'"1��,�V /1 � , Q� ��`�'! �� f"i U� IiJR y r c�tyiz;P � 9�,'��o,� So �� 5 S e d �e uJ � If in a Subdivision provide information, as follows: i� � n L Name: Section: Block: Lot: Date home corners flagged: �p � y This is to certify that the information provided is correct to the best of iny.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 subnutted in this application is falsified or changed. I, also, ui:derstai�d t/iat I an: respoiisiGle for a![ c/iarges incurred fi•onr tl�is application. I, hereby, give consent to the Authorized Representative of the Davie County IIealtl� Department to enter upon above described property located in Davie County and o�vned by to conduct all testing procedures as necessary to deternune tl�e site suit bility. f � ` DATE � � �� SIGNATURE 'ILJ �t2 �(�=�, j� THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed pro r lines and dimensions, st • es, setbacks, and se tic locations). _ \ Site Revisit Charge � � � � �� Datc(s): / �� Client Notification Date: �3� � ` � EHS• � �, � � Sign given �� Account No. �CJ � Revised DCH (OS/03 Invoice No. � � � -_ � :< . .. . ,. . ,i . .. . . . • � �. � , . i ir. . . - , ' . , . . � ��y . . . . 64 � ` �-_._.�. �-.... (2.20A} 6117 ►��. � �.. . ", � ;� c� � N � � W (.S . I I H) 6962 � (1.03A} � N N N 7871 N (25�) r-- ►�,. � , , � � � �� (�188) __ � � ° � ' � a NORTH CAROLINA �� DEED OF EASEMENT ��,,,.,��.�f� DAVIE COUNTY (�� y n�2�A�z�°� �� oel��• /�.� r�c� ��-� THIS EASEMENT, made and entered into this the 21ST DAY OF FEBRUARY, 2003 by and between AI�INIE S. FRYE, WIDOW AND CAROLYN ATWOOD, SINGLE hereinafter referred to as Grantors and THOMAS KEITH FRYE hereinafter referred to as Grantee. WITNESSETH: WHEREAS, T.HE GRANTORS are the owners of a tract of land as set forth in DB 126, PAGE 758 AND DB 52, PAGE 184; and whereas the grantees desires to obtain an easement across said grantors property as hereinafter set forth. NOW, THEREFORE in consideration of the payment of one dollar and OVC to the grantors by the Grantees receipt of which is hereby acknowledged, the Grantors do hereby reserve and convey to the Grantee his heirs, successors and assigns a perpetual non-exclusive easement of ingress, egress and regress and utilities easement and being more particularly described as follows: See attached Exhibit "A" IN WITNESS WHEREOF, the Grantors have hereunto set their hands and affixed their seals, this the day and year first above written. / ii. ' _� . I � i ' , / I � uJ�✓I� �� L�L�� NO H CAROLINA COUNTY � I, ,1��')'Jirc�,�r�i�''`'� Notary Ptjblic do h personally came before me and acknowledge the due execution of the foregoing instrument for the purposes therein expressed. ,3 Witness my hand and official seal, this thea ��y of , 200ij�. �a� s�r�a�, , . ��°� ' . � � w��. } (seal) � a�u � +�e�s� t�; NOT PUBLIC r�� , ,; 4.,,�ou�,.� .,,,�,�.,��,�•�``� My commission expires: �/"�v/d� _ � Exhibit "A" Frye Lying and being in Fulton Township, Davie County, North Carolina and being at a unmarked point in centerline of easement, said unmarked point being located in the western line of Thomas Keith Frye, DB 170, page 175 and being located South O1 degrees 43 minutes 00 seconds VVest, 77.54 feet from existing iron, said z�:isting iron being located in the southern Iine of Carolyn tltwood DB 128, page 758, said existing iron being further located South 89 degrees 20 minutes 44 seconds West, 500.71 feet from an existing iron, said existing iron being the southeasternmost corner of said Carolyn Atwood DB 128, page 758 and the northeastern corner of Thomas Keith Frye DB 170, page 175; thence from said beginning unmarked point North 50 degrees 55 minutes 18 seconds West 120.71 feet from to a point; thence North 53 degrees 27 minutes 07 secands West, 57.26 feet to a point; thence North 32� degrees 41 minutes 16 seconds West, 26.81 feet to a point; thence North 21 degrees 23 minutes 58 seconds West, G6.19 feet to a point; said point being located in the southern line of said Atwood; thence North 21 degrees 23 minutes 58 seconds West,l2. 64 feet to a point; thence North 45 degrees 42 minutes 21 seconds West, 39.01 feet to a point, said point being located in the center of Cornatzer Road SR 1605 and being a 20 foot easement of ingress, egress and regress from the western line of Thomas Keitti Frye to the center of said Cornatzer Road as surveyed by Tutterow Surveying Company, Tax Map Reference I-6 Parce162,64 and 65. � ,•�"~ . � DAVIE COUNTY HEALTH DEPARTMENT . � � Environmentai Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990003022 Billed To: Thomas Frye Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5758-75-6962 Subdivision Info: Location/Address: Cornatzer Rd-27028 Property Size: 1 acre Date Evaluated: � Water Supply: On-Site Well Community Evaluation By: Auger Boring Pit HORIZON I DEPTH Texture group �,...,.....e..,,e HORIZON IV DEPTH Texture group .- .............. .... SITE CLASSIFICATION: �� LONG-TERM ACCEPTANCE RATE: � REMARKS: Public Cut 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- Tenace 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 frm 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 Mineraloav 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/99 (Revised) ■■ ■■ ■■ ■■ ■■ ■■��■�■ ■■�■��■ ■��■��■ ■��■ ■��■ ■��■�■ � ■ ■\ ■�■■ ■�■■ ■■�■ ■��■ ■��■ ■��■ ri\■ ■��■ ■�■■ ■�■■ ■��■ ■�■ ir ■ � ■ ■�■��■�■ ■��■�■■ ■■��■ ■��■ ■■��■■■ ■■■��■ ■■■�■■�■ ■�■��■ ■�■��■■■ ■��■��■ ■�■��■■■ ■��■ ■�■■�■■■ ■�■��■ ■�■�■■ ■��■�■ ■��■��■■ ■■�■��■■ ■��■�■ ■��■��■■ ■�t■��■ ■��■■�■ ■��■�■ ■��■��■■ ■��■�■ ■��■ ■��■��■■ ■��■■ ■��■ ■��■ ■��■ ■ ■■��■■ ■��■■ ■��■�■ ■■��■■ ■■■��■ ■��■ ■��■�■ ■��■■ ■■��■ ■�■��■ ■��■ ■■��■■ ■��■ ■■��■ ■��■ ■��■ � ■�■\�■ ■��■■ ■��e _��■ ■��■■ ■�■��■ ■■■��■ ■�■��■ ■��■ ■■��■ ■��■ ■��\■■ ■