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775 Dulin RdDavie County Health Department 33�8 j� Environmental Health Section P.O. Box 848 C� 210 Hospital Street Q �'t Courier # : 09-40-06 1911 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Name:Ltm-clAPhone Number W(A Of (Home) Mailing Address: %� /� (Work) �e, ,/ i E Email Address: Detailed Directions To Site: &&00000067 R Property Address: 11,6- bAliAl 52rn'1[IN kA) ZI �P - 3 Please Fill In The Following Info rmation About The EXIS lTING Facility: Name System Installed Under: &6"0 Type Of Facility: �S Date System Installed (Month/Date/Year): Zp O % Number Of Bedrooms: 3 Number Of People: Is The Facility Currently Vacant? Yes No If Yes, For How Long?, Any Known Problems? Yes 0 If Yes, Explain:, Please Fill In The Following Inf 5rmation About The NEW Facility: Type Of Facility: 6/G(,� �� /� I Number Of Bedrooms: Number of People Other: Date Requested: �� For Environmental Health Office Use Only Disapproved Environmental Health Specialist_. 01(6'11% *The signing of this form by the Environmental Health Stafths in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment:: Cash Check Money Order # /�//3 Amount:$ �� Q, d Date: [ 0 —/ S` -/Z Paid By:�Vl e /4iil Received By: IR L/l/l�Pi/� _ L -, i Gl Account #: q�-/ �%OO� �3 Invoice #:� i -I,-SSIoz Davie County .Health Department pts Environmeptal Health Section . P.O. Box 848 210 Hospital Street Courier # : 09-40-06 1911 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Name: I ✓ I e Phone Number 510 % OF (Home) ?7 =Mailing Address: 2 (Work) l Q( ✓ i GILIL Email Address: Detailed Directions To Site: &&0000008 LR, Property Address: ' l b- Gt /IV Rd. TM I /lq f Qit1 �G�.t) A1��i tp —,3 Please Fill In The Following Infformation About The EXISTING Facility: Name System Installed Under: / e Type Of Facility: �S Date System Installed (Month/Date/Year): ,90q Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? res No If Yes, For How Long? -Any Known Problems? Yes to,) o)If Yes,' Explain: Please Fill In The FollowingZf rmatioii About •The NEW Facility: Type Of Facility: O / d L-� Number Of Bedrooms: Number of People Pool Size: Garag ize: Other: Requested ate Requested: (Sign re) ; ..\ 'For Environmental Health Office Use Only Approved Disapproved omments. Environmental Health Specialist Date: /0 Z *.The signing of this form by the Environmental Health Staff is in no way intended nor should be taken as a guarantee (extended or limited) that the on-site wastewater system.will function properly for any given period of time. Payment: CashCheck Money Order # Amount:$60 Date: 10—IS-12— Paid By: / Cl: �fll��i�r Received By:"", NiL.�(6/1 ;A�S�q�1 t_ *,ccount #:y�� �03 Invoice s Printed:Oct 15, 2012 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 arty 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. DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account #: 989900063 OPERATION PERI Ll PIN/EH #: 5850-70-0820 Billed To: Larry McDaniel Subdivision Info: Reference Name: Location/Address: 775 Dulin Road-27028 Proposed Facility: Residence Property Size: 2.87 ATC Number: 4874 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed in compliance with Article i 1 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 I `(� Cc Tank Date Tank Size d Pump Tank Size ,/f 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 #: 989900063 Tax PIN/EH #: 5850-70-0820 Billed To: Larry McDaniel Subdivision Info: Reference Name: Location/Address: 775 Dulin Road -27028 Proposed Facility: Residence Property Size: 287 ATC Number: 4874 Site Type: Aew ❑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 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. 1 Residential Specifications: # Bedrooms # Bathrooms 22 # People ( Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Lot Size ) , 7 4 C f -r S Type of Water Supply: �unty/City ❑ Well ❑ Community Well System Specifications: Design Wastewater Flow (GPD)) 60 Tank Size:6AL. Pump Tank Z GAL. /ere / Trench Width 3 w"' Max. 1" Max. Trench Depth3 Rock Depth AWLinsarFt, Site Modifications/Conditions/Other: As stated in 15A NQAQ IRA i oAqp) Systems may also be use Contact the Davie County Environmental Health Section for final inspection of this s 8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760. tee- u ' d � cl s� 0° 1 Environmental Health DCHD 11/06 (Revised) M between `U • ' Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 IMPROVEMENT PERMIT Account #: 989900063 Tax PIN/EH #: 5850-70-0820 Billed To: Larry McDaniel Subdivision Info: Address: P.O. Box 577 Location/Address: 775 Dulin Road -27028 City: Mocksville Property Size: 2.87 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 I revocation if site plans, plat or the intended use change. Permit Type: 0$4ew ❑Repair ❑Expansion Permit Valid for: 95 Years ❑No Expiration Residential Specifications: # Bedrooms 3 # Bathrooms 4T # People Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD): `�� Type of Water Supply: 26ounty/City []Well ❑Community Well a r^ g ated in 15A MC.Ar ISA.1969(•5) Site Modifications/Permit Conditions: amepted Sys—cLm& :nay also be used rd C /I (n��Zlr` �;C' Environmental Health Specialist i.p.11-06 LTAR 1 I Pf i v -c u.- 0 )Date ii APPLY - 1 SITE EVALUATION/IMPROVEMENT PERMIT & ATC J Davie County Environmental Health (i p� P.O. Box 848/210 Hospital Street 1 �e ,ti „�.-''')1�� 0 1 Mocksville, NC 27028 0Lb ` (336)751-8760/ Fax (336)751-87861 i` 1 khon For: f provement Permit ❑ Authorization To Construct(ATC) "oth stem ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***NT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INF TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed L �-/ Contact Person e Billing Address - U� �' Home Phone City/State/ZIP �' (j Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged 5/21ty/d f NOTE: A survey plat or site plan must accompany this application. Included: Ptite Plan ❑Plat(to scale) (Permit is valid for 60 months witO site plan, no expiration with complete plat.) Owner's Name ,-0) M c- AS �1 Y- Phone Number Owner's Address City/State/Zip Property Address f717 j i.:. -1 p, City,{`'`/vJ 1 ju -y- Lot v Tr�T Lot Size ' Tax PIN# c7 � 0-70- Ono Subdivision Name(f applicable)Section/Lot# Directions To Site: L '�'/ _ �,� ; 1 ' IV - ) ,J [_ If the answer to any of the following questions is "yes", supporting docurn gtation must be attached. Are there any existing wastewater systems on the site? (p'Yes ❑No Does the site contain jurisdictional wetlands? ❑Yes o Are there any easements or right-of-ways on the site? ❑Yeslo Is the site subject to approval by another public agency? ❑Yes Ef4o Will wastewater other than domestic sewage be generated? ❑Yes ©foo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms' C8 # Bathrooms Garden Tub/Whirlpool es ❑No Basement: ❑Yes 92G6Basement Plumbing: ❑Yes Q'Ifo, IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBu' siness 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:. OConventional ❑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 Rggo 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 permits) 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 for the proper identification and labeling of property lines and corners and locating and flagging Aropertyrers or staking the house/facili�Iocation,roposed well location and the location of any other amenities. L 11 Site Revisit Charge r owner's legal representative signature Date(s): Client Notification Date: Date EHS: 4° Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # _ N APPA&Cck 'fT#INB®99QMBON Billed To: Larry McDaniel Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation Tax PIN/EH #: 5850-MMMIry INFORMATION Subdivision Info: 1 ,?6 010 (� Location/Address: 775 Dulin Road -27028 C Property Size: 2.87 Date Evaluated: _�_ '7—os; Water Supply: On -Site Well Community Public Evaluation By: Auger Boring Pit. Cut FACTORS 1 2 3 4 5 6 7 Landscape position�-- Slope, % : - HORIZON I DEPTH _ Texture group G Consistence It/ ' S tructure (�S Mineralogy P HORIZON H DEPTHIV Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE aL O • � SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: �' Z EVALUATION BY: OTHER(S) PRESENT: AO REMARKS: V P4 a^'J 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 CONSISTFNCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm Y&t NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic 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 LYQte� 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 (Reviced) - - f5,. � .. 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Cat < 2" &P Fnd %r4w or bm 0WOMb M �� w .leo at* sops abi'VIP" NA IM 0m of Wh oaitl Ar wnwft: r* Wafts am*d to aw ftoft *It fMey be SJf 1/3! = ,,,, , : dite4oe4 � 0 1M wMi aoorllo�e tf66 owa11. N011 �� '�" at of *As dolt. -- - � RRS Fnd -- Site Tkiir "I"of d"AWdoewmenift ON WATili"10 to 16W sapNlM4rttsd . j mmew wd tib M w o�M W by Gem ^^__ ------- +• + .. k{ ppardtted � . y $� Lod Suroeylr19 W. Tie Lyle Tie Line S 0JM12'05"E S 02037.30"N' 25&W' Z F 300.05' j �A r Ch v7 CC14 Heple S.R. Dulin Road I S.R. 1632 60' Public R/IN j 18'+/ Pavement r 1 I I I 1 1 Road 1636 R/W - V40 -o/-V* EIP - E>ieltaq Yon Plps OR £tdetkrg k.n Retvo P - PW CM - Concrete Mwwm+wnt C/A - controlled Asset CP - Concrete Pipe CAP - Cenegolnl, Melo) " CPP _ CwnNyfNtod Pbdk pipe -F- 100 Year Man! Boundary -0- Overhead tet Nee -X- Fence Fid - Found n/f - Mew amFont nerly CL - CL 61 tkw wntod Pont lop - £days of IN mom TP Tillpl+eNw Pedestal -111.- refer tLa Tax Lot 88 TCW bop 0-6 n/f Donnie Burt McDaniel DB 82 • PC 199 Comb" Bolt Fnd Gravel Drive Crosses Property Line 14 '- ---------------- S 87e53'43'r 573.75' -----, -----------moo'-fi'-'------------- ---------------------------------- ;---- 1t Gravel Drive Crosses Property Line 41.87. , (227x' ) - --- -- - -Old. One Story. ' Covered T16.49' — - — Frame House �%L? - ap Cow►ed �j - - , SlobPr Proposed Pbrr:N Building - 10' x 10' Well Now" TP _ 1 o7.aT Concrete Monument ° ✓ Found z N O / IV 09 it NCDOT Concrete R/W Monument Fnd o � I Proposed pp House Site o Proposed Septic System Area J 1 � PP j o� I 4e.osa• j 31.19' 47.18' 606.42• N�=mow i Tax Lot 87 Tax Map G-6 2.877 Acres +/- (213.57') arifiMld copies of t11w so w" mop wM not bo mood beyond nkwtyM) days of tlw orlo survey date, f :Y Napier 11M. _ p Map not for . n1otien. SR ism Durr" SR ism Prsomm 1:10,000+ , YlcwtilYMap to Sc) S Notar. Existing field rnonwnentat in dWs not Ei fdng with recorded PbViittid data. moflunsrtatorr haled tea' cones: r, 4- W1211 W/211 Drive Shaft Bent/Fnd N vA Tax Lot 88 A Tax Map G-6 ro n/f Donnie Burt McDaniel two DB 82 O PG 199 1"VPFnd Tax Lot 86 Tax bop G-8 n/f John Bruce While and We Billie A. Powe White DB 142 O PG 564 4 Z Dulin Road S.R. 1632 I 1 " EIP Fnd FC - Face of Cub 1 9oC - Bock of % MM PP - Power Polo LP - u9m Pols MH - Mon Holo CH - Chord Dhftwm P/0 - Pot of DB - Deed Book P9 - Plat Book R9 - Record Book PG - CB - = &..,- 6- eamS- Sewer Line MIM - Waft Meter WV - Mhlhr Ndhvs 9M - as d Marie TOM - 9ench Mort RRS - W SPNNe CiV' - CaMe Television Pedestal EM - Elocbk TNawforrner Box 00 - Sanitary Serio Clean Out 4 comp Rabort awe, PiefooMed Lard >iWwW, L-316'2. OMAN) be ono of No P.—I so MONANd Nam ® Or Site Improvement Survey Performed ❑ e. not Ni pet b of ♦ "weW go anon s 0040 0 d lead ewhln on 12-18-1997 Reference Job %S 14997 W dee d a 000eyr Or eeev:Mft sut Jtso • MAlewo Hut r.rybw Peer. of bee; ❑ b. ad'tib plat b d M aM.ey 6tad b heeled b wmu p 11 Of e 01001410 of 1 w'f - i• •e • rte• Plat Revision: 5-27-2006 1. PfOpO>fed House, Bt1 lnQ. Septic System Area Q a 1 MK b M e own" of On diem pwd or p* of 1W4 .[ � ❑ d. 11ao1 sdt pot b d 0 oMrey d w�ur' n Id, Md ae tele O�L O`�/ $/0 reeewddMdlon d airMe pMseM• a dept-adrN rw1 or or+ogfion ` l» derMI&P d U664@06 r �. ❑ o. jhd W kMwnaNM aueeobM b sAf wevya b errdl► Mut 1 ave+ t declare that On v . 2 . SEs{. ' enable 1" fraw a dflonrdn.An+tb tMr haft d nV pelydfrrl eMwr t to MerilMu aaefMwd M � tleoa�ll t�4 fir` we the property shown on 0 L-3162 43 this plot: 04 l �61�,SU George R. Stone � RO BER Lsed leneye6 L -3M Survey for: Larry K. McDaniel Tax Lot 87, Tax Map G-6, Record Book 455 O Page 736 Tract 16 2.877 Acres+/- by coordinate geometry SCALE TOW SIW Cvtwry sea¢ cm 1 " 601 Farmington Davie North Carolina 5--22-2008 2*4.nv: Stone Land Surveying, Company o SC,D8,RS ow" tt low ftwo, PLS L-3162 3608 _ MAPPM 151-$ South Maim St (336) 998-4733 MAP NO. GRS Mocksvift, N.C. 27028 Y �' � a- � >• ;, �. a .. ' _