225 Bear Creek Church Rd, Lot 3 Davie County,NC Tax Parcel Report Tuesday, October 18, 2016
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BEAR CREEK
BEAR CREEK CHURCH RD CH RD
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WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number. E20000002816 Township: Clarksville
NCPIN Number: 5811471927 Municipality:
Account Number: 82531340 Census Tract: 37059-801
Listed Owner 1: BAKER JUSTIN C Voting Precinct: CLARKSVILLE
Mailing Address 1: 225 BEAR CREEK CHURCH ROAD Planning Jurisdiction: Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-20
State: NC Zoning Overlay:
Zip Code: 27028-0000 Voluntary Ag.District: No
Legal Description: LOT 3 ANGUS ESTATES Fire Response District: WILLIAM R.DAVIE
Assessed Acreage: 0.73 Elementary School Zone: WILLIAM R DAVIE
Deed Date: 12/2009 Middle School Zone: NORTH DAVIE
Deed Book/Page: 008130817 Soil Types: MnC2,MnB2
Plat Book: 0007 Flood Zone:
Plat Page: 068 Watershed Overlay: DAVIE COUNTY
Building Value: 92610.00 Outbuilding&Extra 1150.00
Freatures Value:
Land Value: 15600.00 Total Market Value: 109360.00
Total Assessed Value: 109360.00
91 v iE All data is provided as Is without warranty or guarantee of any ldnd either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS websfte shall hold harmless the
County of Davie,North Carolina.its agents,consultants,contractors or employees from any and all claims or causes of action due to
�'outJ cs NC or arising out of the use or inability to use the GIS data provided by this website.
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AUTHORIZATION NO: ' 9 3 7 DAVIE COUNTY HEALTH DEPARTMENT, V
' ;Environmental Health Section PROPERTY INFORMATION
Permittee's "' P.O. Box 848
Name: Mocksville,NC 27028 Subdivision Name: Me �' a f�
Phone# 336-751-8760 /
Directions to property: _r%' ( <°�/ ✓'(� Section: l 'Lot: .t
AUTHORIZATION FOR
WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN:# r3a� - - .!
Road Name: Zip: a� .
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Peimits.This Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(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
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPEPAVDATE ISSUED
' ? DAVIE C UNTY HEALTH DEPARTMENT
IMPRO EMENT AND OPERATION PERMITS PROPERTY.INFORMATION
Perinitteels �,
Name: M .off Subdivision Name: lt
Direciions to property:: r, +r `•i`,• �' 'Y '' Section: /' Lot: +� "
IMPROVEMENT
PERMIT Tax Office PINA!rv/ -U-C
.20Road Name: Zip: .
**NOTE**,This Improvement Permit DOES NOT authorize the construction or installation 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 Articled l of G.S.`,Chapter 130Aj Wastewater Systems,Section.1900 Sewage Treatment and Disposal.Sy stems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SP `IALIST r DATE SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS#BATHS _#OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE' #PEOPLE/SHIFT #SEATS I/NDUUS�TRIAL WASTE:Yes or No
LOT SIZE.//A TYPE WATER SUPPLY c Q DESIGN WASTEWATER FLOW(GPD) 'Ted NEW SITE /'F REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZF1�GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.--1
OTHER
REQUIRED'SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
*"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH RTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30'-9:30 A.M.OR 1:00-1:30 P.M.ON THE DA ALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT , D
SbvM INSTAL D BY:
goo
'� EA.ccD
T
140us� .
AUTHORIZATION NO. t " OPERATION PERMIT BY: DATE: L/
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT S STEM DESCRIBED ABOVE 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.
DCHD 05/96(Revised) ".
C -�
Davis County
Health Department "
1`�._.rr ;
Environmental Health SeWOH
P.O. Box 868/210 Hospital Street ,A,I
Mookaville, NC 27028 sur 1 5 1999
(336)751-8760
ENVIRUNI4 _._
***nV0RTANT*** THIS APPLICATION tTUMV BE PROCESSED UNLESS ALL -- kA t3Y
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for i=trnaticns ~ -
Mame to be Billed \ � � / Contact Person .`�/(�`jf V - {�
Mailing Address i� Ham Phone
City/state/LIP 1 Business Phone
Nam& on Pemit/ATC It Different than Above
flailing Addreas city/state/Lip
]Application For: U Site Evaluation 0 Improvement Permit/ATC Both
System to service: House 0 Mobile Home 0 Business 0 Industry 0 Other
If Residence: # People i Bedrooms _ / Batbrooms �
0 Dishwasher 0 Garbage Disposal 0 flashing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
If Business/Industry/other: specify type # People # Sinus
# commodes # showers # Urinals # Nater coolers
IS M13SERVICE: II Seats Estimated Water Usage (gallons per day)
7. Ty,.a of water supply: �Couftty/city
0 Well 0 comummity
s. Do you anticipate additions or expansions of the facility this system Is intended to serve! 0 Yes 0 No
If yes,what type?
***IMPORTANT'**CLIENTSAIUSTCtiAMETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BES�UJBMITTED b the client with THIS APPLICATION.
Property Dimensions: �]n (-S 9 .� `7 WRITB IItECTiONS(from Mocicsvule)to PROPERTY:
fig' Ili� DO��IE�� e�
Tax Office PIN: rE {SII i✓ 7y L4& 7Y GF/
Property Address: Road Named2K-
City/Zip LL6F 270ZY
If in a Subdivision provide iurormation,as follows:
Name:
Section: Block: Lot: 0 Date Property Flagged:
Nis is to certify that the information provided is correct to the best or my knowledge. I understand that any permit(s)
ssued bereafter are subject to suspension or revocation,If the site plaits or intended use change,or if the information
bmitted in this application is falsified or changed. I,also,understand that I am ra poi iffilefor all charges lncumrd front
his appJicwkn. I,hereby,give consent to the Authorized Representative of the Davie Coon Health Department
o enter upon above described property located in Davie County and owned by t..4��
o conduct all testing procedures as necessary to determine the site suitability.
ATE SIGNATURE
IIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(include all of the following: Existing and proposed
roperty lines and dimensions, structures, odbacks, and septic locations).
Account No.
evised DCHD(07/98) Invoice No.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LO ?--4
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED `
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION � ./l[ rSD� ROAD NAME
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring_ / Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position 2— L
Sloe%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure �C
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: l EVALUATION BY: e
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
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(01-90)
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SIDIVISIONPLAT•APPROVALh.•---•� !AY 4,.••J�TTERo!L-•------» ••-•••----��rdythatthisplatwasdrawn
under my supervision from an actual survey made under my supervision(deed description
North Carolina................_......County
plat meets the recording requirements of the Subdivi• recorded in Book 1.7.1 g._......!.35,••_•... .................. —:Page3491 9?c j (other): 1,a Notary Public of the County and State aforesaid•certify that
County and.if applicable,that a that the boundaries not surveyed are clearly indicated as drawn from information found in
s been Issued by the Division of Highways pursuant o G.RAQY...6,..TUTTERQW............................._.aRegisteredLand
f the General Statutes,State of North Carolina Book............................................Page.....................;that the ratio of precision as Surveyor•personally appeared before me this day and acknowledged the
calculated is 1:..Z.Z,.W.Q..............:that this plat was prepared in accordance with G.S. execution of the foregoing instrument.Witness my hand and official stamp or
47.30 as amended.Witness my original signature,registration number and seal this Ist seat,this.......I#t...............................day of.D..S.Mbst........,19-93............. T
y of_ _ ._ _...._....._._ ..19....._........... day of.......... ..........gFMMbsr ........A. 19 95 _ f
........ ...... ...
Notary Public
_.
.............................................. ............................... ..._.S u
DIRECTOR OF PLANNING (Seal or Stamp) PoistIQon Number' Seal or Stamp My commission expires....................
,,`���unnrrrr4
CARO�•.,���
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/ .
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162.43 total U-85 77.0
/S7— I 246.67 B;
�D 493,33 total
fp Da ,�{eF4 3 ���'r% Pll r v¢.r ry
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00
:, J T APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
R Davie County Health Department
Environmental Health Section
r P. O. Box 665 '
Mocksville, NC 27028
1. Application/Permit Requested By. `I
Mailing Address S �P IF �� U Home Phone 'T� -s-3n
Business Phone
2. Name on Permit if Different than Above
3. Application for. General Evaluation *Septic Tank Installation Permit �.
4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly .
❑ Business ❑ Industry / Other ❑ Unknown
5. If house, mobile home:Subdivision HC Section Lot #
I
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 3 ❑ Washing Machine
No.of Bathrooms Z ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6.•If business, industry, place of public assembly, other: Specify type
No.of People Served No. of Sinks
No. of Commodes No. of Urinals
i
No.of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: 2rPublic 1�)5�9� ❑ Private ❑ Community
8. Property Dimensions 2.7-40 '4GQ'",/Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No '
If yes,what type?
r /9,"NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
,
PROPER2:11 INFORMATION REQUIRED:
.A
Directions to Property: Tax Office PIN: # y>1 }
I_�,'i U i so PROPERTY ADDRESS, as f d i l OTS:
Road Name: l lYCrPPK AUrc� �
,
N. ' y � y�
G�I cls G. City: 11�YKS!))LLC- N_C.
Q-n f 2var Crime k uvc� SUBMIT A PLAT WITH THIS APPLICATION.
6S Or 1��`� . Revisions effective October 1, 1995.
�;�
poy
This is to certify that the information provided is correct to the bestof my kno led and I understand I am responsible for all charges
j incurred f m thi ap lic tion.
i
i DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
f MUST CHECK ONE: 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
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 all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system. _
i
DATE SIGNATURE
DCHD(1199)
1
. ' •DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section /r
Soil/Site Evaluation
NAME V4 Awl DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY LOCATION OF SITE ZY
Water Supply: On-Site Well _ Community Public s_,l
Evaluation By: Auger Boring j/ Pit Cut
FACTORS 1 2 3 4
Landscape position Z.,
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure S iC Ship
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: , OTHER(S) PRESENT:
REMARKS:
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-Vc.-y 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
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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A TUTTEROW North Carolina........................County
IAL SUBDIVISION PLAT APPROVAL I,........G..R..AY....4................................................................certity that Plat
drawn
under my supervision from an actual survey made under my supervision(deed descoreon 1 a Nota Public of the County and State aforesaid:certify that
That this plat meets the retarding requirements of the Subdivi• recorded In Book....I7l...r.........135, ,,,,•,,.••••.....................:Page349r..... ) ( ) Notary
GRA4Y•.l •.TUTTEROW a Regist
for County and,if applicable,that a that the boundaries not surveyed are clearly indicated as drawn from information found n
............... ...
royal has been issued by the Division of Highways pursuant to gook............... .......-.....................,Page...... . ............;that the ratio of precision as Surveyor,personatly appeared before me this day and acknowle
22 OQO that this plat was prepared in accordance with G.S. execution of the foregoing Instrument.Witness my hand and official
.4136 of the General Statutes,State of North Carolina calculated is 1:........r...................... y
47.30 as amended.Witness my original signature,registration number and seal this 1st seal,this.......I.1...............................da o1.D.4.COm frf.........,
i ......................19:................. y December Not u
I........day of............................... da of.............................................. 9.95..... ......
• Notary Public
i4S tiU My commission expires............
h Seal or Stamp
............................................ Seal or Stamp) egistration Number'
r DIRECTOR OF PLANNING
CAR
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AREA r 2.240 ACRES
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frP a
. .rDd e C&qn Xedltfr Department
and Xaio e Yfealtfr ffyency
• 210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634-5985
February 21, 1996
Larry Tyndall
335 Bear Creek Rd.
Mocksville, HC 27028
Re: 2 Site Evaluations
Angus Estates/Lots 2 & 3
Dear Mr. Tyndall:
As requested, a representative from this office visited the aforementioned
sites on February 19, 1996. Based upon the information provided on the
application(s) for site evaluation(s) and after the evaluations were completed,
the sites were' found to be provisionally suitable for the installation of an
on-site sewage disposal system on each lot.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosure(s)
cc: Jesse Boyce, Zoning Officer
i ,
-`.,,hF +.n.,.--tiT� r"iFe�=t s't� ...crsn dl •.vv a:«a)T-9.Ji'1p Yia^`•� 4-.P'T '.,z-t.-�P"k'J �`*".' rreev�►
AUTHORIZATION NO: 1936 DAVIE CUNTY HEALTH DEPARTMENT
,k:° environmental Health Section PROPERTY INFORMATION
Permitter( i ...... �/J P.O.Box 848
Name: J r Mocksville,NC 27028 Subdivision Name:
Phone# 336-751-8760
Directions to property: Section: Lot: tto
AUTHORIZATION FOR p
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION F
Road Name: Zip: a'
**NOTE**This`Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building-Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance'with Article 1 I'of,G.S.Chapter 130A,Wastewater Systems,Section.1900Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
141 q IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
..l
i
9 3 6 DAVIE UNTY 111EALTH DEPARTMENT
r. An, �• ' IMPRO EMENT :OPERATION PERMITS PROPERTY INFORMATION .
Permitted'S= // /
,Name: . : Y, r " t 1 Subdivision Name., Of
Directiorfs to property .^ :': � + ' Section: Lot:
IMPROVEMENT
PERMIT
Tax Office PIN:#- �
Road Name: };�+tC Zip:
NOTE This Improvement Penn it DOES NOT authorize the construction or installation of a septic tank system** ** mor 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 I I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
`/ AL,/ `J �• ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE. .
N C` INSTALLING THE SYSTEM.
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST.'. DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
RESIDENTIAL SPECIFICATION:BUILDING TYPE_ #BEDROOMS y�#BATHS #OCCUPANTS GARBAGE'DISPOSAL:Yes or No 'y
COMMERCIAL SPECIFICATION:.FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE, /Xee .TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD)J�� NEW SITE_J�� REPAIR SITE
i
SYSTEM SPECIFICATIONS: TANK SIZE .��0 d GAL. PUMP TANK GAL. dt
TRENCH WIDTHG ROCK DEPTH LINEAR FT.
OTHER '(
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
11 lg
N .
, U
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30-9:30 A.M.OR 1:00 1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT /
SYSTEM INS�ZLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: _
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL'INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I OF G.S.CHAPTER 136A: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.
17-
DCHD 05/96(Revised)
APPUCAIION FOR SITE EVALUA11UN/IMPROVEMENT PERMIT&
Davie County Health Deparbnent
' • _ Envimamenta/Hea/tfi Section
P.O. Box 868/210 Hospital street
�.. 5
Mockaville, NC 27028 1999
(336)751-8760
F111VIRONMEN
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed � o / contact Person
Mailing Address r LHome Phone � `7�C5
City/state/LIP ) Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/state/Lip
3. Application For: U site Evaluation 0 Improvement Permit/ATC Both
4. system to service: _House 0 Mobile Home 0 Business 0 industry, 0 Other
a. If Residence: # People # Bedrooms _ # Bathrooms
0 Dishwasher 0 Garbage Disposal U Washing Machine 0 Basement/Plumbing 0 Basement/No Plumbing
6. If Business/Industry/other: specify type # People # sinks
# Commodes # showers # Urinals # Water Coolers
IF FOODSERVICE: it seats Estimated slater Usage (gallons per day)
7. Type of water supply: County/City 0 Well 0 Comeaunity
e. Do you anticipate additions or expansions of the facility this system is Intended to serve? 0 Yes 0 No
If yes,what type?
"AIMPORTANT"'CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUI U[ITTED by the client with THIS APPLICATION.
Property Dimensions: n '�` nS 9 + Li WWRRI DIRECTIONS(from Mocksvilie)to PROPERTY:
Tai Office PIN: # 1 ���w OciS 4o!' D��$ �F GOI /✓ '7a 14&-4r_7Y Ch/ ew
Property Address: Road Name � �o•`rlG-
City/Zip 41ZJ4�✓41._ 27074
If in a Subdivision provide information,as follows.-
Name:
ollows:Name: 4 �� >✓
Section: Block: Lot:
Date Property Flagged:
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 ani reVonsiblefor all charges incurred f-om
this application. I,hereby,give consent to the Authorized Representative of the f� nor Health Department
to enter upon above described property located in Davie County and owned by �' 7M4 Gtr
to conduct all testing procedures as necessary to determine the site suitability.
DATE 1^'1�" � SIGNATURE
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).
X\
Account Na
Revised DCHD(07/98) Invoice No. 7"(0
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOTZ•2
Soil/Site Evaluation
APPLICANT'S NAME / DATEEVALUATED
PROPOSED FACILITY t PROPERTY SIZE
SUBDIVISION ROAD NAME
Water Supply: On-Site Well Community Public
Evaluation By:, Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position 2—
Slope
2-Slo e%
HORIZON I DEPTH \
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH '?4r
Texture group
Consistence r
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: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: 4. OTHER(S)PRESENT:
REMARKS:
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
Moi t
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(01-90)
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