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169 Corries LnDavi�CoU:nty, NC T�� U�,-��1 u o,,,,.-r Wednesdav. October 12. 2016 VVHt�lrllrli: 1111.71.71�V1 Ei�7U1tVP.Y � Parcel Information Parcel Number: N60000004107A Township: Jerusalem NCPIN Number: 5755400225 Municipality: Account Number: 82523766 Census Tract: 37059-807 Listed Owner 1: BOSS FARM LLC Voting Precinct: JERUSALEM Mailing Address 1: 229 BOXWOOD CHURCH ROAD Pianning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overiay: Zip Code: 27028-0000 Voluntary Ag. District: No Legal Description: 10.783 AC OFF BOXWOOD CHR Fire Response District: JERUSALEM Assessed Acreage: 10.81 Elementary School Zone: COOLEEMEE Deed Date: 12/2004 Middle School Zone: SOUTH DAVIE Deed Book / Page: 005880136 Soil Types: PaD,PcB2,PcC2 Plat Book: Flood Zone: Plat Page: Watershed Overlay: Building Value: 0.00 Outbuilding & Extra Freatures Value: Land Value: 65590.00 Total Market Value: Total Assessed Value: 26050.00 °"°:`F Davie County, �o�;r�; NC DAVIE COUNTY 6460.00 72050.00 _ ;. _ - , . . -, _ ,..:-, : _ ,. . , , ; _,. . ,.,:: ,.. :: :. . & t/','/•� d'' , , �;:_ f -• � . �: �. f.i . �S �x o , AUTHOR�ZAT�ON 1v0: Q$$$ DAVIE COUNTY HEALTH DEPARTMENT ,� >� � " Environmental Health Section PROPERTY INFORMATION Permittee's ,,�' P.O. Box 848 Name:�/}Z/C�,�f�'f�� Mocksville NC 27028 Subdivision Name: , � '7 / Phone #: 704-634-8760 Directions to property: ��^��, `r �;;�;. ;-_ Section: Lot: �� , AUTHORIZATION FOR �� �� ``�" �'` "�r�� �� � '� SYSTEM CONSTRUCITON Tax Office PIN:# ���� - � - ��. � �J Road Name: �01'Y'1,�� ��p: r i� Q **NOTE** 'fhis Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any Building Pernuts. This Forn�/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pern-uts. � (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ' �- ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �'`1 l%'�^;i �`: ��•'�.� � . •' {,; � �'�i �// i�� IS �'ALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH S�PECIALIST DATE ISSUED , _ , , � '� :�,:'✓'.'`,: r" ;r. r.: ':.:. . , .:. . - �Dffr�D. � .a�, v' " .,, ,.:� ' " 'I; � ,,. t. 1 . DAVIE COUNTY HEALTH DEPARTMENT �`� �"4'� IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION -^'€..';r` ,i . . Pernuttee's �- � Name: '� ` =a.��4�'lf�....:�'��#�i e� �� Subdivision Name: � Directions to property: �"`� "r r� ��,- -- �? • Section: Lot: < Il�IPROVEMENT . �� , , .. � / i: ,� � :-,�' f' � � . ,�' PERNIIT Tax Office PIN:# �r �- � - � « - G���i � f- Road Name: L.�U i't'�'c:' �� r�.e:;t'Zlp• .�� `(;''r �} **NOTE** This Improvement Pernut DOES NOT authorize the const�vc6on or installa6on of a septic tank system or any wastewater system. An - ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCI'ION must be obtained from this Department prior to the construction/installafion of a system ar the issuance of a building pernut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERNIIT LS SUBJECT TO REVOCATION IF SITE '� ''r`'' PLANS OR TFIE INTENDED USE CHANGE. YOUR WASTEWATER � ��;'' :"' � � �- - � � �. ���� ��'��. f`�� ,%r �'/ ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE ,�'/� # BEDROOMS �� # BATHS .c� # OCCUPANTS �'� GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE J-,� TYPE WATER SUPPLY ��✓f% DESIGN WASTEWATER FLOW (GPD) 'J �� NEW SITE r/ REPAIR SITE ,• � SYSTEM SPECIFICATIONS: TANK SIZE 1�t�GAL. PUMP TANK GAL. TRENCH WIDTH .?l, , ROCK DEPTH _,%% LINEAR Ff. �1 �d OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT f **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 930 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. T'ELEPHONE # IS (704) 634-8760. I OPERATION PERMIT � 3 7S� *� . . �t/ INSTALLED BY: W�-V h `�o +1-S r'1. �lom� r0 � �` S : �-e. '(aZ �• r+.,-c- U(= '� �S{�2C.T• F)+'` • Ct1\ �.;ti..e.e�0• K�- �e�.�� AUTHORIZATION N0. ��� 8 OPERATION PERMIT BY: DATE: ��� ���/ **THE ISSUANCE OF THIS OPERATION PERMTT SHALL INDICATE TH T THE SYSTEM DESCRIBED ABOVE 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. DCHD OS/96 (Revised) . APPLICATION FOR SITE EVALUATION/IMPROVEMENT Davie County Health Department Environmental Health Section P.O. Box 848 Mocksville, NC 27028 � (704) 634-8760 1��� 0 L/ � �D r�AY i s i9�7 � . �'�'�'�IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed� � qrn'. Q e�m'. �`n Contact Person �: e.5 m, T j"1 Mailing Address "G �,g �Xv �OOC1 C.1'� `� �1 Home Phone �0 7- Z�� ` Z 7 J�i City/State/Zip ��.�CS U�� I 1 e. /U C Z 7� 2� Business Phone 7G �I Z� �- •"/� J� � 2. Name on PermidATC if Different than Above Mailing Address City/State/Zip 3. Application For:�Site Evaluation [] Improvement Permit & ATC 4. System to Serve: [] House � Mobile Home [] Business .[] Industry ', [] Other [� Both ✓ � 5. If Residence: # People� # Bedrooms� # Bathrooms � [] Dishwasher [] Garbage Disposal � Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing , . 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers , � , If Foodservice: # Seats Estimated Water Usage (gallons per day) - 7. Type of water supply: [] County/City [] Well [] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? (�Yes [] No If yes, what type? T'c� rn►` l � ��► 7�. EZTHER tl PLfIT OIZ � PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** 2�}i�;frOF THE PROPERTY MUST BE SUBMITTED WITH �S APPLICATION. Property Dimensions: � �� �C,C`� � � WRITE DIRECTIONS (from ocksville) TO PROP R7 Tax Office PIN: #�' 15 S-. � b_- O 7_ 7'� ; �� v O"� �' Property Address: Road Name C� o t'�''� ��S L/�j � ' C � ' 'r' "6 City/Zip /�(l�c: �� U �►-� � '�' ; � C ��C vJ0 � If in Subdivision provide information, as follows: ��� S+ CI O r'C�� f ' .c h � 2 Name: � Section: Lot #: ; � � O � �'e � � c 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 I am responsible for all charges incurred from this application. 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 p `� , n by 1� SS C�hS�� v.L�"��"�1 C 1��S`'j�� ��o conduct all testing procedures as necessary to determine the site suitability. DATE S/`j —� i SIGNATURE ��C��� v��� Revised DCHD (06-96) THZS AREA MriJ $E USE� �'OR bltttWlNC� �OUR SZTE YLtIN: \, `' � � � � �:�,~ � � � 5 :,,, � . : � _ .,-=. � 1 . � �C� �, ;� 7 �\ � 1 � \ ` ,� J ' �/'j . . . � .T � � 1 `. � �/ CJ .� �`y� ;1 , i r � � � � � v � J ., � •- �� f,1�, •1 �--- � �,� . � ,r,, u ` `^ . 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DATE EVALUATED �v � �% PROPOSED FACILITY _�f�' PROPERTY SIZE ��� SUBDIVISION Water Supply: Evaluation By: On-Site Well t� Community Auger Boring ✓ Pit ROAD NAME Cl��'1`�`ES' .L/�-t- Public Cut SITE CLASSIFICATION: � EVALUATION BY: ��`� LONG-TERM ACCEPTANCE RATE:� OTHER(S) PRESENT: REMARKS: DCHD (01-90) 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 Mineraloev 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 ■�■��■�■■�■■■■■�■■�■�■����■■■ ■�■��■��■��■��■���■��■��■■■■■ ■�■■■■■■■��■��■����■�■���■■■■ ■■���■��■�■■��■■■■■■�■■�����■ ■�■■■■■■■��■�■■����■�■�■■■■■■ ■���■■�■■��■■■■■�■■■�����■■■■ ■�■��■��■��■��■���■■�■■��■�■ ■�■�■■�■■��■�■■��■■���■ ■��■ ■�■�■■�■■��■��■���■���■�■■■■■ ■�■��■��■��■■�■■■�■■■■���■��■ ■�■�■■��■��■�����\■��■■�■■■■■ ■�■�■■■■■��■��■���■��■���■��■ ■��■�■■�■■�■■■■���■■■■���■■■■ ■��■■■■■■■�■��■������■��■■■�■ ■����■■�■■�■■■■■■■■■�■��■■■■ ■�■■■■■■■��■������■■■■■ ■■■■ ■��������■�■��■■�■■■■■������■ ■����■��■■�■■■■■■■■�����■■��■ ■�■■■■■■■���������■■■■■�■■■■■ ■�■��■��■��■��■���■■■■■��■■�■ ■��■�■■����■��■���■■�■■��■■�■ ■■■■�■■�■■■■��■■��■■■■■�■■■�■ ■■����■��■�■������■■�■��■��■ ■��������■■■■■��■■�■�■■ ■■�■ ■��■�■■�����������■■■■■�■■■■■ ■��■��■��■������■�■■�■■��■■■■ ■■■■��■��■■�■��■���■�■■�■■■■■ ■���������■■■■■■�■■■�■■��■�■■ ■■�■��■���■�■������■■■■��■■■■ ■■■■�■�■��■�■■■■■■����■■��■■■ ■���■�■■�■■�■��■������■�■■■■ ■■�����■��■�■���■■�■■■■ ■■■■ ■■■■■■�■■�■�■���■�����■■��■■■ ■■�������■■�■��■■�■■■■■■�■■■■ ■�������■�����■��■�■■��■■�■ ■■�■■■�■■■■■■■■���!=������� ■■■■■■�■■■■■�ii��■�■■��■■■■ ■■��■��■■����I■���■�■■��■■�■ ■■��■■�������1�������������■ ■■■�■��■■�■�11■���■�■■ ■���■��■■��■11■���■�■■ ■�������■�■�11■■��■��� ■■■■■■�■■■■■r�■■■■�■■ ■■■■■■�■■■■�■■■■■■��■ ■■������■����■��■■�■■ ■��■�■ ■■��■■ ■■■■�■ ■����■ ■��■�■ ■■■��■ ■�■■�■ ■��■�■ ■�■�■■ ■���■■ ■���■■ ■■�■��■ ■■����■ ■■■■■■� ■����■ ■■�■��■ ■�����■ ■��■��■ ■�■■■■■ ■����■■ ■�■��■■ ■��■�■! ■■�■■■■ ■��■��■ ■■■■��■ ■�■���■ ■�■��■■ ■■■■■�■ ■■■���■ ■�■�■�■ ■■ ■■■�����■■ ■■■����■■■ ■�■����■■■ ■�■�■■■■■■ ■��������■ ■�■■����■■ ■��■■���■■ ■�■■��■■■■ ■�■�■■■■■■ ■■■■■■■■■■ ■�■����■■■ ■�■�����■■ ■�������■■ ■■■■■■■■■■ ■��������■ ■■■■■■�■■■ ■������■■■ ■��������■ ■�����■■■■ ■■■■���■ ■■■■■■■■ ■������■ ■��■���■ ■■■■■■�■ ■��■�■■■ ■■�■■�■■ ■����■�■ ■�■■■■■■ ■�■��■■■ ■����■�■