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129 Gray Carter LnApplicant: Tammy Bracken Address: 129 Gray Carter Lane City: Advance State/Zip: NC 27006 Phone #: (336) 940-2004 For Office Use Only 'CDP File Number 137629 - 1 County ID Number: Evaluated For: HDR/WWC PERMIT VALID 0 4/ 3 0/ a 0 1 9 UNTIL: /11p�-roperty Owner: Tammy Bracken Address: 129 Gray Carter Lane City: Advance State/Zip: NC 27006 \Phone #: (336) 940-2004 Property Location & Site Information Address 129 Gray Carter Lane Subdivision: Phase: Lot: Road # Advance NC 27006 SINGLE FAMILY Township: 'Structure: Directions # of Bedrooms: 4 # of People: Hwy 64 East tum Left on Fork Bixby Rd. to Livengood Road, then Gray Carter Lane 'Water Supply: NIA Basement: ❑ Yes ❑ No Type of Business: Total sq. Footage: No. Of Employees: 'Proposed Improvement: Storage Building This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: 'Date: 'Issued By: 2140 -Nations, Robert 'Date of Issue: 0 4/ 3 0/ a 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** B;Hand Drawing Olmport Drawing HEALTH DEPARTMENT RELEASE a,.sr„a �1 1 Davie County Health Department 210 Hospital Street " P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Tammy Bracken Address: 129 Gray Carter Lane City: Advance State/Zip: NC 27006 Phone #: (336) 940-2004 For Office Use Only 'CDP File Number 137629 - 1 County ID Number: Evaluated For: HDR/WWC PERMIT VALID 0 4/ 3 0/ a 0 1 9 UNTIL: /11p�-roperty Owner: Tammy Bracken Address: 129 Gray Carter Lane City: Advance State/Zip: NC 27006 \Phone #: (336) 940-2004 Property Location & Site Information Address 129 Gray Carter Lane Subdivision: Phase: Lot: Road # Advance NC 27006 SINGLE FAMILY Township: 'Structure: Directions # of Bedrooms: 4 # of People: Hwy 64 East tum Left on Fork Bixby Rd. to Livengood Road, then Gray Carter Lane 'Water Supply: NIA Basement: ❑ Yes ❑ No Type of Business: Total sq. Footage: No. Of Employees: 'Proposed Improvement: Storage Building This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps. Signature: 'Date: 'Issued By: 2140 -Nations, Robert 'Date of Issue: 0 4/ 3 0/ a 0 1 4 Authorized State Agent: **Site Plan/Drawing attached.** B;Hand Drawing Olmport Drawing RECEIVED Date: 2!!tJ)PAM -, Recelvc� 3 -,/ Davie County Health Department 6 E -vironmental Health Section a ' 1 P.O. Box 848 ' • 210 HosI)iW S(1 -CCL Q 'S Courier # : 09-40-06 Mocksville, NC 27028 Mimic: (336) - 7.53 - 6780 Fax: (336) - 753.1680 ON-SITE WASTEWATER CERTIFICATION (Cy�heck One) Replacement Remodeling Reconnection I o Name: cth /h v 8cetc �y e✓1 Phone Number 33 & — 9'10 �-- a4t?y (Home) Mailing Address: /off 9 G rcw Ga T L c-� .336/FJ — 4;Oe7 (Work) Ad yem&/e/, /1/G a-Zr�� pe h Iu l I V.ha0 . co m Detailed Directions To Site: /-/I- L/ Ya/` SLY" Aj -70 2— %, r� NJ O G r r r ani Property Address: /;2q G rQ, ��E� 7 e � l-1., /a E,.i yec„ice~ Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under- n.y �G%Qf, Type Of Facility: c5;.���c �av,,;�,. �[�P/��•j� Date System Installed (Month/Date/Year): Mot --els 60 I Number Of Bedrooms:/—Number Of People: —3 Is The Facility Currently Vacant? Yes 6DIf Yes, For How Long? Any Known Problems? YesI O If Yes, Explain: Please Fill In The Following Informatiion About The NEW Facility: Type Of Facility: 044— 8u 11 I'h4 _ Number Of Bedrooms: 40— Number of People ':2: Pool Size: X051 / Garage Size: /l/Other: Requested By: Date Requested: (Signal For Environmental Health Office Use Only Appro Disapproved Environmental Health Specialist`� il%�%/��I� Date: </,/"/ 141 *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 # mount$ Date: Paid By: Received By: Account #: ! Invoice #: 137 (I1 -q DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990000934 Tax PIN/EH #: 5778-36-2587015 Billed To: Tammy Cope Subdivision Info: Reference Name: Tammy Cope Location/Address: Livengood Road -27006 Proposed Facility: Residence Property Size: 1 Acre **NOTE-** Tliibginprovement/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 Z #Bedrooms #Baths Dishwasher: 12K Garbage Disposal: ❑ Washing Machine: C?" 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: New B' Repair ❑ System Specifications: Tank Size jff 00 GAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width'" 'Rock Depth /2 Linear Ft. IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 K BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the 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 the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: —/0 -OCD DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990000934 Tax PIN/EH #: 5778-36-2587,,3 Billed To: Tammy Cope Subdivision Info: Reference Name: Tammy Cope Location/Address: Livengood Road -27006 Proposed Facility: Residence Property Size: 1 Acre ATC Number: 2317 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 WASTEWATysf, CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: W. Date: , o �- /�` C.CI CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 1 I 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. 8 1 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) L -14Y . APPUCATION FOR SiTE EVAWA7iON/IMPROWMFM PERMR B ATC Davie County Hesith Department ' Env/ronma nt'wl Hew/& SwOon Ilk P.O. Bos 969/210 Hospital Street Mockavillej HC 27029 (336)751-8760 D 1----1 JAN 5 UIVIROVIENTAL HLALiil r0u r ***IIlpART1LNT+�** =111 A>:n2CATION ©um BE == SM t1NLB88 ALL s""VBQUIAED INFORMATION 18 i?R-O'VIDZD. to the XWOMMION SOLISTIN toot instructions.. /Rai6r 1. Mass to be Billed -Fa rrn r �/ C ()'Q Contact "coon l'1 a by ra r f l , r� -� i�e�f p Bailing Address ] W " I I- �ye n Qnl Jl 1 11 d noes cityhtatelssa rr(Ci VQ ncP,,Inc fhoa.(_ ")�(�) q 9 "'_I 170 -r���D �sSusiness Z. Maas on permit/ATC it Dittarent than Above 1►,iril r n 1. cc 2 Hailing Address I �� , _� lQ �i t 1 UPnC��� city/state/sip - -Od MUCP r� -7/� (,, �t /� d 0 0I0 a. Application For: O Site !valuation 0 Improvement permit/DTC Both s. systes to services 0 House ) tobile Roma 0 Business O Industry 0 Other s. It Residence: ! people # Badroome _3 f Bathrooms �- U Diahwasher O Garbage Disposal 04sabing Machine O Daaessnt/pluobinq O Sasesent/No pit binq t. s! Stains**/tA&strr/otbar: specify type 0 people i sinks # Commodes + shomme 1 t:rlaaai* i Water Cooler* if FOODSIIRVICE: # Seats Metimated !tater Usage (gallons per day) 7. Type of water supply: County/City ❑ Well ❑ Commmity e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yee 0 No If yes, ghat type? **e'IMPORTANP** CWENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: j acre - Tax Office PIN: # 5-7-7 Y J (..P 25g I Property Address: Road Name L i UP n ct Q. JCJ Pd City/Zip hd u o n Cf 27 r! .Q If in a Subdivision provide information, as follows: Name: Section: Block: lot: WRITE DIRECTIONS (from Mocksville) to PROPERTY: Tri Ke b Hr i ko3 Turn Lef-r nn ForK 13 i (bV Gt n 2 or r� y,eW0V on R «�4T Trail r Date Property Flagged: D 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, it the site pians or intended use change, or if the information submitted In this application Is falsified or changed 1, also, anderatand that I ant responsAk for all charges Incurred from this appUcadom 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 to conduct sH testing procedures as necessary to determine the site sAtabWty. it DATE I / r-) ILV U — SIGNATURE 11x13 AREA MAY BE USED FOR DRAWING YOUR STl'E PLAN'(Inctude all of tbeYollowing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): I Client Notification Date: EAS: Revised DCHD (07/49) Account No. �l Invoice No. /��� (Wo) 194 (11.3; 861 808 173 W 1Lt=1 - a 140 150.90 1 -". A210) I I ,. (3q3) • .: - - 790` G.0 .- (179) (174) 79Q' J f (143) A)12 7169 Y 8198 Xl.A 1 1 g ; (2.36A) (1.49A) 8086 0075 u 3095 14001 13 (, UOA, � 16_4 _ ) 8858 12 210 10 (145) 750 � - 49 7 N � w (392) r " •' (1148A) a 166 s I 2587" (t41) A) -730(299 ff 5475 N 1 • 9403 r (, 0)20 '168 Y _ 391 661. -f (Wo) 194 (11.3; 861 ti APPLICANT INFORMATION Account #: 990000934 Billed To: Tammy Cope Reference Name: Tammy Cope Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5778-36-2587 Subdivision Info: Location/Address: Livengood Road -27006 Property Size: 1 Acre Date Evaluated: A21X SA.0� Water Supply: On -Site Well Community Evaluation By: Auger Boring [/ Pit Public Z ---- Cut FACTORS 1 2 3 4 5 6 7 Landscape position ,Z . Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH 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 SITE CLASSIFICATION: ll LONG-TERM ACCEPTANCE RATE: I y REMARKS: EVALUATION BY: ,li /Z 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 - 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 FR - Friable FI - Firm 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 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 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 DCHD 05/99 (Revised) ■■■■■■■■■■■■■■e■■■■■■■■■■■■■■■�■■■■■■■■■■■■nee■■■■■■■ ■■■e■■■■■■■o■■■■■■■■■■■e��e■e■ ■■■■■■■■■■eee■■■■■■■■■ ■■■■■■■■■■■e■■■see■■e■■■■■■■■■■■■e■■■■e■■■■■■■e■■eee■■ ■■■e■■■■■■■e■■■■■t■■■■t■■■■■e■■■nee■■■nee■■■■e■■■e■■■■ ■■■■■e■■e■■■■■■■■■■■■e■■■■■nee■■■■■■■■■e■■■e■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■e■■■eee■■■e■o■■■■■■■■o■■■■■■e■■■■■■■ ■■■■■eee■■■e■■■■■■e■■■■■■■■■■■■■■■■■e■■■■■■■■e■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■nee■■■■■■■ ■oo■e■■■■■■eee■■■■■■■o■■e■■o■■■■■e■o■a■■■m■enn■■■■■■m■ ■■■■■■■■■■ee■■oeem■eee■■■■m■■em■o■e■■ee■o■■■■e■e■ne■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■eee■■■on■■■■m■■■■n■■n■■oeeoomeee■■■n■■n■■■■m■eo■■e■■■ ■■■■■■■■e■■e■■■e■■■em■■■e■■■■e■■■■■■■■nee■nee■■e■■■■■■ ■■■■eenn■e■■nee■■■■■■nee■■■eee■■e■■o■■■■■■■e■■■■■■■e■■ ■no■■eee■■■■■■■em■o■eee■■■■■e■�■n■■■ee■ee■e■ee■e■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■nee■■■■■■■■■■■■e■■n�■.�■■�_ ■■■■■■■■■■■e■■■■■■■■■■ ■■oe■■■■m■ee■eee■■■■■■■n■■■■■■■e■e■■■■n■■■■■r�■e■■■■■■■ MONSONMENNENiiiiiiiiiiii ■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■nee■■■■■■■e■■nee■■■■■e■ ■■■■■en■■e■■■■■■■■■■■■■■■■■■nee■■■■■■■■■e■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■e■■■■■■■■■e■■■■■■e■■■■■■■■■■■■■nee■■■■■e■■■■■■■ee■■ ■ee■nm■eee■■■■■■n■■■■■ee■■■■■e�■■■■ee■e■■■em■■■n■■■e■ ■■■■■■■■■■■■eee■■■■■■■■i■■■■■■■■■■■■■e■■■■i■■■■■■■■e■■■■ ■■■■■■nee■■■eee■■■■■■■■i■e■■■■■■nee■■eee■■i■■■e■e■■e■■e■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■i■■■■■■■■meet■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■�■e■■■■■■■■■■■■■eee■■■■ ■■e■■■■nee■■■e■■■■■■■■■i■me■■e■ ■e■■■■e■■e■■e■■■■■■■■■ nee■■■m■■eee■■■■■eom■e■e■■e■■ee■m■■■■■■■■■■nee■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■nee■■■■■■■■■■■■■■■■■■e■■nee■■■ ■■■■eee■■■■■■■■■■■■e■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■nee■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ME no ii ■■ estabrohed minimum bwld"ug setback lines and dedicate oil streets.' olleys, walks, parks and other site* end easement to public or r / '—--------- —'-----� private use as noted. Furthermore. 1 hereby dedicate oil sanitary O sewer and water linos to the County of Davie DATE` c r h r 1 MORFMON G. CARii:R treREN R, D.B, CLARK 159, PG. 7163 z! P SITA& My R BRACKEN N I IV D.B. 9 .. 284 I 6 W, PIN, ,366854 EIP o I I 4 {i REVIEW OFFICER'S CERTIFICATE f, Review officer of Davie County, certify that the map or plat to which this certification 2%) N ¢ —� I s as•u•oO• e is affixed meats all statutory requirements for recording. z I REVIEW OFFICER DATE NEW 40' rAS040a AS Or rEs-25-2oi- -1 I �A I. Grady L Tutterow, certify that this plat was drawn under my supervision from on actual wrvey made under my supervision {dead dascrf tion roeorded in Book -- Page etc) �ther),-that the boundaries not surveyed are clearly indicated as drawn from information found in PL Book Page — that the rctio of precision is calculated as It +2 OOO that this plat was prepared in accordance with G.S. 47-30 as amended. Witness my original signature. registration nu era aeol day of Fig �-�4 NJ.P — 4724 \• N &I—SSW l"e �` 7ZZ NJJ' fs/v LQt ! `70`— MOP•RISON G. CARTER /}/e w AB 82, PG. 672 3� 0,Lr Qu,id:!25 D.B. 96, PG. 689 PIN# 5778362587 Pot4 t3u:►�•►� AREA= 1.754 AC. TAKEN FROM PINI 5778362587