1097 Farmington Rd`
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
i
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Brian and Tommi Boger
Address: 1097 Farmington Rd
City: Mocksville
State/Zip: NC 27028
Phone:::
Pro
Address/Road _�:
1097 Farmington Road
Mocksville NC 27028
Structure: SINGLE FAMILY
of Bedrooms:
of People:
'Water Supply: N1A
'IP Issued by. 2244 - Daywall. Andrew
'CA issued by: 2244 - Daywal;. Andrew
Design Flow: 4 8 0
Soil Application Rate: 0 1 5
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width.-
Aggregate
idth:Aggregate Depth:
'CDP File f4untber 122217-1
E500000001413
County ID Number:
Evaluated For: HDRMWC
y Township:
Property Owner: Brian and Tommi Boger
Address: 1097 Farmington Rd
city'. Mocksville
State!Z ip: NC 27028
Phone:
erty Location & Site Information
Subdivision: Phase: Lot:
9 n n ft.
Directions
1-40 East to Farmington Rd. Turn Left. House is on
left just after Pinebrook Dr.
'System Classification/Description:
Saprolite System? C)Yes ONo
'Distribution Type: GRAVITY - PARALLEL (eq. d -box) Purnp Required?
QYes ( I'lo
'Pre -Treatment:
Drain field
Sq. ft.
QInches O.C.
Feet O -C.
___8Inches
Feet
inches
Minimum Trench Depth:
f0inimum Soil Cover.
Maximum Trench Depth:
faaximum Soil Cover:
Inches
Inches
Inches
Inches
'System Type: INFILTRATOR QUICK 4 STANDARD
Installer. bebee backhoe
Certification
' EH S: 224.1 - Day v.alt. Andrew
Date: 0 9/ 1 6/ 2 0 1 3
Approval Status
❑ Approved ❑ Disapproved
CDPFile Plumber 1222.17-1
Manufacturer.
STB:
Gallons:
Date:
'Filter Brand:
Yes
❑
No
ST Marker.-
❑
Yes
❑ No
einforced Tank:
❑
Yes
❑ No
, 1 Piece Tank:
❑
Yes
❑ NO
Manufacturer.
PT:
Gallons:
Date:
Riser Sealed ❑
Yes
❑
No
Riser Height: ❑
Yes
❑
No (rtin.6 in.)
forced Tank: ❑
Yes
❑
No
1 Piece Tank: [:1
Yes
ElN
0
Pipe Size: inch diameter
Pipe Length: feet
"Schedule:
Pressure Rated ❑ Yes ❑ No
,pproved fittings ❑ Yes ❑ NO
County ID Number: E500000001,113
Lat.
Long:
Installer:
Certification :
`EHS:
Date: / /
Approval Status
❑ Approved ❑ Disapproved
Pump Tank
Installer.
Certification r:
'EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
_j
Supply Line
Installer:
Certification
"EH &
Date: / /
Approval Status
❑ Approved ❑ Disapproved
f Pump Type: Installer:
r/ Dosing Volume: - Gal Certification
Drag Down: Inches 'EHS:
"Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check -valve ❑ Yes ❑ NO Approval Status
PVC unions ❑ Yes ❑ No ❑ Approved ❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti -siphon Hole 0 Yes ❑ No
. CDP'File Number, 122217-1
County ID Number: E500000001,113
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
❑ No Approval Status
El No ❑ Approved ❑ Disapproved
224.1- Daywatt. Andrew
'Operation Permit completed by:
'i�nAuthorized State Agent: JDate of Issue: 0 9/ 1 6/ 2 0 1 3
This system has been installed in compliance with applicable 14C General Statutes: Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A .1900 et. Seq., and all conditions of the Improvement Permit and
Construction Authorization. This property is served by a sewage septic system.
Rule .1961 requires that a Type _______,___ septic system meet the following criteria:
Minimum System Review By The Local Health Department:
(management Entity:
fitinimum System InspectionR,laintenanceFrequency ByCertified Operator:
Reporting Frequency By Certified Operator:
Rule .1961 requires that a Type IV and V septic systems designed fora home,'business owner must maintain a valid contract
with a public management entitywah a certified operatoror a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora home business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity priorto the
issuance of an Operation Permit for a system required to be maintained bya public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shalt also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Activity Code: S-19 204 - OP issued NEW Type 11 Quick 4
Total Time.(HH.1.11,1)
0 1 Hours 3 0 lunules
F-11cLu11k. r-yurHn1Cnt
EMAU Box or Equivalent
❑
Yes
❑
No
Installer.
Box 12 inches Above Grade
❑
Yes
❑
No
Certification »:
Box Adj. To Pump Tank
❑
Yes
❑
No
Conduit Sealed
❑
Yes
❑
No
"EFTS_
Pump Manually Operable
❑
Yes
❑
No
'Activation Method:
Date:
Alarm Audible ❑ Yes
Alarm Visible ❑ Yes
❑ No Approval Status
El No ❑ Approved ❑ Disapproved
224.1- Daywatt. Andrew
'Operation Permit completed by:
'i�nAuthorized State Agent: JDate of Issue: 0 9/ 1 6/ 2 0 1 3
This system has been installed in compliance with applicable 14C General Statutes: Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A .1900 et. Seq., and all conditions of the Improvement Permit and
Construction Authorization. This property is served by a sewage septic system.
Rule .1961 requires that a Type _______,___ septic system meet the following criteria:
Minimum System Review By The Local Health Department:
(management Entity:
fitinimum System InspectionR,laintenanceFrequency ByCertified Operator:
Reporting Frequency By Certified Operator:
Rule .1961 requires that a Type IV and V septic systems designed fora home,'business owner must maintain a valid contract
with a public management entitywah a certified operatoror a private certified operator forthe life of the septic system.
Rule .1961 requires that Type VI septic systems designed fora home business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity priorto the
issuance of an Operation Permit for a system required to be maintained bya public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shalt also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Activity Code: S-19 204 - OP issued NEW Type 11 Quick 4
Total Time.(HH.1.11,1)
0 1 Hours 3 0 lunules
OPERATION PERMIT
Davie County Health Department CDP File Number: 122217-1
210 Hospital Street E500000001413
P.O. Box 848 County File Number:
P.locksville NC 27028 Date:
O inch
DrONIAawing Drawing Type: Operation Permit Scale: O = ft.
/tom
3 telj C
too
PUPi
r1p
f
Applcant
Address
CON'$TRUCTION For office Use and
AUTHORIZATION `CDP Fite Number 122217-1
Davie County Health Department County ID Number E500000001413
210 Hospital Street Evaluated For HDR/WWC
P.O. Box 848 Tovinshlp
Mocksville NC 27028, FERl.'IT', ALJ_: Jti-I_
Phone: 336-753-6780 Fax: 336-753-1680 0 7/ 1 6/ 2 0 1 8
Brian and Tommi Boger
1097 Farmington Rd
City Mocksville
State Zip NC
Phone
27028
E0
Addres, s Road SUI)OVIs10"",
1097 Farmington Road
P.1ocksville NC 27028
Slruc% re SINGLE FAMILY
of Bedrooms
of PeOJIe
"A'ater Suppfy .N:A
Property Ov.r er Brian and Tommi Boger
Andress 1097 Farmington Rd
Cry Mocksville
Sate Zia NC 27028
i Phone =
on & Site Information
Prase Lo"
1-40 East to Farmington Rd. Turn Left. House is on left
just after Pinebrook Dr.
Page 1 of 3
System Specifications
1.1+ninuvn Trench Depth
3 0
'S:te C18SSIf at Ott PS
Inctles
i'
t.11nlrnurn Soa Cover
Cover -
Saprolite systenr? f. i�;)n0
Inches
Desion Flow. 4 8 0
t.taxanurn Trench Death
3 6
.... I r1C eS
Soil Appl:catlon Rate 0 1 5
t.taximlinl SM Cover
In^'res
'Systein C assif:caucn Descr,pnon
'Distnhunon Type
GRAVITY- PARK -LEL ic,.7 t;oxl
TYPE II A. CONN SYSTE'.1 iSM;LE-FAMILY
OR 4M GPD OR L ESs, Septic T ank
Gallons
'PrnpOSed S4'jten1 27;;. REUUCTK)N
; -Piece
(" )Yes (J N 0
Pump Regr;lred :')Yes
}alto C;L'ay Be Required
Nitrification Field
Sq ft Puma Tank
Gallons
No Drain Lwes
; -Piece
(:Yes (_)llo
Total Trench Length 2 0 0 f,
P1.1 -v S-- t TDH
T reach Spac-ng
4 ahiches 0 C
:x>Fee' 0 C Dosing Vo'Unle
Gallons
Trench Width
CAnch$s
_
Feet
Grease Trap
Gallons
Aggregate Depth
_
_
nchcs
Pre Treatment _.a NSF
aTS-1 0 -TS -II
Sep'icTank
Installer Grade Level Required c�.al
r ?II 4: alit '. alit
Page 1 of 3
'CDP Flle tlurnrer 1,22217'-1
Coan:y ID tll.mber E50000001413
❑ Open PumpSystem Sheet
Repair System Required _)Yes (') No C)No. but has Available Space
Repair System .
Trench Spacu)q !)Inches 0 C.
`Site Classification PS — t�) Feet 0 C
Trench W,Oth ( ) Inches i
Design Flovi 4 8 0 — :v)Feet
Aggregate Depth
Soil Application Ra -P 0 1 --- inches
L':�,:nirt�;un, Trench Depth 3 0
`System Classifica,ion Descriptio; Inches
TYPE 11 A CONY SYSTEM iSINGLE-FA",LILY OR •180 GPC OR LESS; L!, n irn t I rn Sol Cover
Inches
Llay rmum 'I tench Depth 3 6
'Proposed System CONVENTIONA,_ Inches
M xm,um Sol' Cover
ilrnfi,,ation Field Inches
Sq ft
No, Drain Lines 'D;str:butnnType GRA'YITY- PARALLELieq d -box)
Total Trench Length$ 0 0 ft Pump Required (- Yes —)[Io r :,F.'av Be RPqu rPd
Pre Treatment )NSF ':=:)TS -1 r: -7S-11
'Site Modifications
No giadw.g or construction: actrirty is allov.,ed in areas desicnated for system a;,d reaa:r ',rithout approva`- of Ifealth Departnrer:t
'Permit Conditions
The Issuance of this permit by the Health Department in no vay Guarantees the issuance of other permits The permit hol0er
is responsible for checking viith appropriate governing budgies in meeting their req,,iirenterits.
This Authorization forWastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit not
to exceed five years, and may be Issued atthe sametime the Improvement Permit Issued (NCGS 136A -336(b)). If the installation has not teen
completed during the period of validity of the Construction Permit the information submitted in theappllcation for a permit or Construction
Authorization is found to have been incorrect falsified or changed, or the site is altered, the permit or Construction Authorization shall become
invalid. and may be suspended or revoked (.1937(g)). The person ce.vning or controlling the system shall be responsible forassunng compliance
with the latus. rules. and permit conditions regarding system location. installation. operation. maintenance monitoring. reporting and repair
(1938(b)).
Applicant Legal RPP; Signature Regwred? i)Yes '`?No
App'rcant Legal Reps. Signature Date
'Issued By 22:1-1 -D3y,:ail. A,e: c:. D of Issue 0 7/ 1 6/ 2 0 1 3
_ Date
A,;thowed State Agent
t.falfu^c,,on Z.^,g (~>Yes
Hand Drawing :_:)Import Drawing �o;a!
**Site Plan/Drawing attached.**
Page 2 of 3 0 1 0 0
-
S-9 - C A ISSUED . EXPANSION
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.0, Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 122217 - 1
County File Number: E5010-00000 14 13
Date: 0 7 1 6 1 2 0 1 3
Scale: Block = ft.
"SIJ A
P,mi-- I of '3
F- 5 OLI(0ODO I N 13
Davie County Health Department
V P 1222 1
Environmental Health Section
P.O. Box 848
210 Hospital Strcct
O U Courier # : 09-40-06
T , Mocksville, NC 27028 RECEIVED
nate: '1 5 13 a�
Phone: (336) - 753 - 67 A Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: 44.24AI WMM7- %30G"iZ Phone Number (Home)
Mailing Address: /D9'7 /40,
l iJcks v�i,C /1/c '2-2azt,
Email Address:
Detailed Directions To Site:-771/0/�F1irs�,— /�� G�T�V /Z -r,3 TZ� /,ci9"-, ALsef
U/1 j ar Jv ST I +'?�JE� U�rvLA-Z_0rf- /0 -/(-
Property
/t_
Property Address:109i 1C IZlJ, !�%veicsyS!/ice /'iiL ;?-702p
Please Fill In The Following Information About The EXISTING Facility: 3.7 q aC -Ls
(Work)
Name System Installed Under: R',V3'WZV- f3y6LR2 Type Of Facility: /&,,S?�y�a+ TtC,
Date System Installed (Month/Date/Year): Number Of Bedrooms: 'ZS Number Of People: S
Is The Facility Currently Vacant? Yes
Any Known Problems? Yes
Nem If Yes, For How Long?
No/f Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility:Number Of Bedrooms:__y Number of People��
Pool Size:
Requested By:
Approved Disapproved
Comments:
Environmental Health Specialist.
Garage Size:
Other:
Requested: -7'3—/.3
For Environmental Health Office Use Only
Date:
*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: Cash Check Money Order # I Z3C1 Amount:$
Paid By: 1� t Cw l t c 1 rzz.� - Received By:_
Account #: I Z Z -L 1'7 Invoice #:
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DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990001029 Tax PIN/EH #: 5841-57-8628
Billed To: Robert Boger Subdivision Info:
Reference Name: Robert B. Boger Location/Address: Farmington Road -27028
Proposed Facility: Residence Property Size: 3.759 Acres
ATC Number: 2355
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 WASTEWAT CONS
TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: 9 - Date:
CERTIFICATE [OF COMPLETION
**NOTE** The issuance of this Certificate of Completion sha in irate the ys em described on Improvement/Operation Permit
has been installed in compliance with Article 11 o G. . Chapte 13 A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall in NO WAY be tak as guarant tat the system will function satisfactorily for any
given period of time.
v
r
u
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990001029
Billed To: Robert Boger
Reference Name: Robert B. Boger
Proposed Facility: Residence
/2W 3,23,00
Tax PIN/EH #: 5841-57-8628
Subdivision Info:
Location/Address: Farmington Road -27028
Property Size: 3.759 Acres
**Nbgmproveme
*Ttiint/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 1'� #Bedrooms #Baths
Dishwasher: e Garbage Disposal: ❑ Washing Machine: Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size --Fj /%e Type Water Supply �� Design Wastewater Flow (GPD)� Site: NewO'Repair ❑
System Specifications: Tank Size/
= GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width -'' Rock Depth Linear FtP-.OP
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of tbd Davie County Health Department 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 ay i stallation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Al .D
Davie County Health Department 1
Environmental Health Section WR 6 2000
P.O. Bon 848/210 Hospital Street
Mocksville, NC 27028 __J
(336) 751-8760 RiV'RMIF C.0 1NTY NLTH
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
L
1. Name to be Billed lI_n �e-,4
sn� Contact Person �Jr-I ao!/QQr�yfklbe-l
Mailing Address (e P Lq,_ Home Phone 7
Business Phone 33V 0City/State/ZIP /&Lp �_l d207 �
2. Name on Permit/ATC if Different than Above SA�Me{�SDOVt?
Mailing Address C ~" City/State/Zi
3. Application For: ❑ Site Evaluation W/111 provement Permit/ATC ❑ Both
4. System to Service: V"House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People -5-,— # Bedrooms 3 # Bathrooms
M Dishwasher ❑ Garbage Disposal Washing Machine 0 Basement/Plumbing O Basement/No Plumbing
6. if Business/Industry/Other: Specify type
# Commodes
# Showers
# Urinals
# People # Sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: &county/City ❑ Well ❑ Community
S. Do you anticipate additions or expansions of the facility this system is intended to serve? es ❑ No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: v` WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: #- _ I,Jti S� �,' s - a,y � 1�iArm,n 2J 1K �/
J I
Property Address: Road Name %i� R� 1 v,� tOi� Ad (PKC. le -A- u)� e -h (4 ce l i %I. f 0 S S over
city/zip 1&1U,1111e,1 �y 8 ri - �/O I'� s o� M k d>1
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
RiI5� old 4'on )e-6kT-hef
i a- (ha;� kX,/"f D°u) Ni;ke.wRm ; s,gyo s (A.
Date Property Flagged: 3 - / - on /I/ -
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 Ivie County Health Depa ment
to enter upon above described property located in Davie County and owned by1,�� �-�- �1; Ani�2T
tc conduct all . ,-t:.M . ..a.._cs a -_ as
j,� .�......g j.o.^.C..u.., w &3 accessary iv uc►c, auiuc auc Ziac �uiiauuud�'_. ,/�
DATE /' 3 -5-- 0o SIGNATURE ��Ig&Xt SA/,. f�7 9&655
THIS 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).
Vle,A'se- 64k` 6A� Q{ FDf2 CVAJV4t10n Site Revisit Charge
q Flo - s'a a 3 Date(s):
Client Notification Date:
I EHS•
Revised DCHD (07/99)
Account No.
G
Invoice No.
I
o—
I
I
I
I o
ROBERT WILSON PITTS ASW
I
KAREN HODGES PITT I
I
o D
DB. 146 PG. 80 /
v
I
I DB. 146 PG. 82
I
A NEW PARCEL OUT OF EXISTING TAX I > -V
I I
I
PARCELS 14.02 AND 14.06 ON TAX MAP E-5
rm
�
1 I
I
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II
JEAN F. SMITH A/H I
I I
JOSEPH B. SMITH I I
I
I
i
II
DEED BOOK 175 PAGE 463
I
I
I I
I
REBAR IRON FOUND ON SMITH'S
I —
— PROPERTY LINE 30' FROM C/L RD. \� I
I
IIRJ
i A NEW PARCEL
I
' CHARLES G. JONES A/W LINDA B. JONES
I
NIP SET 30' FROM THE
I
C/L OF THE ROAD--,,",,,p
:IP AT THE WIRE
-ENCE CORNE
N 88002'07"E 1095.1 6
o
/
Z
X
(NEW PROPERTY LINE)
A=61.83' R=7833.68 N
—
326.42'
Z
p �, PARCEL
S 05°13'42"E 61.83'
(CHORD) NIP
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p
AREA : 3.759 ACRES
Ln
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c; po
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Cnl
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�N_E`N PROPERTY LINE)
.__
m
1
.�----- S 88007'13"W 1104.27'
NIP SET 30' FROM THEJ�
D
C/L OF THE ROADVd
fJ�
m
L
NIP UNDER WIRE FENCE
Z I
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REMAINDER OF
J
n
A
TAX PARCEL 14.06
ELLA A. FURCHES ESTATE
m I
r
I
DEED BOOK 23 PAGE 265
DEED BOOK 72 PAGE 157
m�
N
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L4
i
I
I
EIP AT THE N.E. CORNER OF DANNY F. SMITH p
AND 'NIFE LINDA H. SMITH PROPERTY — SEE GEED I
i
'82.
PAGE 1 G5 TAX PARCEL 14.08 ON TAX GAAP E-`:) - -
6 U • APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department
f Environmental Health Section
�P.O. Box 848 J
51 Mocksville, NC 27028
t 704 634-8760
****IMPORTANT**** 1' THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed r
Mailing Address eS' 6,✓1Aron&z S �.
City/State/Zip /ylcrksL1i11P . a -C'. ag7d
2. Name on Permit/ATC if Different than Above
Mailing Address
Contact Person
Home Phone
Business Phone
City/State/Zip
3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC
4. System to Serve: X House [ ] Mobile Home [ ] Business [ ] Industry [
5. If Residence: # People---J<"
Bedrooms # Bathroomt2
)J Both
] Other
[Dishwasher [ ] Garbage Disposal
'Washing Machine L4 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: IN County/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [X No
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions:Gr/ WRITE
Tax Office PIN: # `7� - / I -
Property Address: Road Named� lln r o,�-. C % �
City/Zip w/i�G�L 5,,,4c ( -
If in Subdivision provide information, as follows:
Name:
Section: Lot #:
vS (from Mocksville) TO PROPERTY:
V"AA 1/2.40—
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
by l- 7.(iZ-� Q.2� to conduct all testing procedures as necessary to determine the site suitability.
rV�� • � ��C:���lb(/iii.. _
Revised DCHD (06-96)
Ste- 4L eqLVeoC '2
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME im6r DATE EVALUATED 9"'A
ADDRESS v r PROPERTY SIZE��l�
PROPOSED FACIILTY LOCATION OF SITE
Water Supply: On -Site Well _ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence �•
Structure Xh AJ
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
SITE CLASSIFICATION: _ EVALUATED BY:
LONG-TERM ACCEPTANCE RATE:
REMARKS: All'11-Si2
DCHD(01-901
ER(S) PRESENT:
i
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 ;lay loam• SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V -y friable FR -Friable FI-Fir'n VFI-Very firm 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
3C --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
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Davie County Heafth Department
andHome -Come Health .agency
Environmenta(Health Section
P.O. BOX 848 / 210 HOSPITAL STREET
COURIER 809-40-06
MOCKSvIUE, N.C. 27028
PHONE: (704) 634-8760
September 2E, 199E
Mr. Roger Brian Boger
185 Pinebrook School Rd.
Mocksville, NC 27028
Re: Site Evaluation/Furches Estate
Farmington Road/Mocksville
Tax PIN: 5841-77-7913/4 Acres
Dear Mr. Boger:
As requested, a representative from this office visited the aforementioned
site on September 20, 1998. Based upon the information provided on the
application for a site evaluation and after the evaluation was completed, the
site was found to be provisionally suitable for the installation of a modified,
oversized on—site sewage disposal system.
If you have any questions, please feel free to contact this office.
Sincerely,
�"j�a��
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure(s)
cc: Jesse Boyce, Zoning Officer