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2010 Hwy 64W - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Account #: 990004020 Tax PIN/EH#: 5729-14-0060 Billed To: W.D Grooms Subdivision Info: Reference Name: Heath Grooms Location/Address: 64W.-27028 ATC Number: Ar-44y5- 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 WASTEWATER CONSTRU TION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: A�11 Date: 4�f`lt),b C 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 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. (:!�o ti,. a�S7D C*r R;e(L- �2t�� I1 IST1�• � -�3, _I �� r � 3 Septic System Installed By: 7R J Environmental Health Specialist's Signatur 7)Date: DCHD 05/99(Revised) ` 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 #: 990004020 Tax PIN/EH#: 5729-14-0060 Billed To: W.D Grooms Subdivision Info: Reference Name: Heath Grooms Location/Address: 64W.-27028 Proposed Facility: Residence Property Size: 2.009 acres ATC Number: 4445 - Site Type:,,211ew ❑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. Residential Specifications: #Bedrooms 3 #Bathrooms#People_3L Basement❑ Basement plumbingJ2-01- Non=Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size 2. 12S Type of Water Supply: County/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) 30 Tank Size GAL.Pump Tank GAL. �r N t Trench Width A nn _(1Max.Trench Depth J/ Rock DepthN A Linear Ft. 22S Site Modifications/Conditions/Other: }.�t Contact the Davie County Environmental Health Section for final inspection of this system between 8:30 4:39,ig,an the day of installation. Telephone#(336)751-8760. 3 � ls' ` F2ov-r ,. ��JI✓1�7 FGt7N?iki loJ f C:'►�'iTi�L��r�s Environmental Health Specialist Date: 7 1 J 70N ub) DCHD 11/06(Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksviille,NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990004020 Tax PIN/EH#: 5729-14-0060 Billed To: W.D Grooms Subdivision Info: Reference Name: Heath Grooms Location/Address: 64W.-27028 Proposed Facility: Residence Property Size: 2.009 acres **Nro` emelt/ :e ation 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 #Bedrooms _ #Baths'x Dishwasher: Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply �G Design Wastewater Flow(GPD) Site: New 0 Repair❑ System Specifications: Tank Size,�6AI GAL. Pump Tank GAL. Trench Width -� � Rock Depth&441-Linear Ft� Other: accepted Systems may also"be use Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAYOUT- APR V D EFFLUENT FILTER RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representati e of thf 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. .o t e day of installation. Telephone#is(336)751-8760.**** 1D / ( / Environmental Health Specialist's Signature: � Date: /D/011'7� DCHD 05/99(Revised) P I 'I SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Health Department ( Environmental Health Section ! ( J U N 2 7 2006 P.O.Box 848/210 Hospital Street I Mocksville,NC 27028 ENVIRONMENTAL HMN (336)751-8760/Fax(336)751-8786 DAVIE COUNTY Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Both ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Contact Person 5API P Billing Address L Home Phone e� - q5e5 o City/State/ZIP_M()C:gSt) tA .(, .J C Business Phone Name on Permit/ATC if Different than Above &L-OA4 A Mailing AddressS li w D 2 Z City/State/Zip LL-e- 0 PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan,no expiration with complete plat.) q� Street Address City /771eCe V,)/.I— Tax PIN# ?•�!r� ~G��a Subdivision Name Section/Lot# Lot Size L.o o T"-, Directions To Site: Date House/Facility Conners Flagged If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes BNo Does the site contain jurisdictional wetlands? ❑Yes 91 o Are there any easements or right-of-ways on the site? fi'f`es ❑No Is the site subject to approval by another public agency? ❑Yes LINo Will wastewater other than domestic sewage be generated? ❑YesLNe IF RESIDENCE FILL OUT THE BOX BELOW #People �— #Bedrooms #Bathrooms Garden Tub/Whirlpool ❑Yes �No _ Basement: &Yes ❑No Basement Plumbing: tes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of FacilityBasiness 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: ❑Conventional fAccepted ❑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 tNo 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 permit(s)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 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections todetermine compliance wit applicabl ws and rules on the above described property located in Davie County and owned yP�TS Site Revisit Charge Property o er's er's legal representative signature Date(s): 7—y(� Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# OZy Revised 2/06 Invoice# DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation. APPLICANT INFORMATION PROPERTY INFORMATION .Account#: 990004020 Tax PIN/EH-#: 5729-14-0060 Billed TO:., W.D. Grooms . Suodivision Info: Reference Name: Heath Grooms Location/Address: 64W.-27028 Proposed Facility: Residence Property Size: 2.009 acres Date Evaluated; /fl, Jfo 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 ,d Texture group Consistence Structure Mineralogy HORIZON II DEPTH " 4 Texture group CG 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 b-3 SITE CLASSIFICATION: EVALUATION 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 clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Is 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) ■■....C.......0■.e.!!..l.:CC...■......................■... ■ lmimimmommommommoommm ■■ / ■ ■aaa.■.O.EEE■EE■e.■■■O■OO.■.O.O.O■...0...■.■■.■■■!■ :::�■■ ■■ ■ :.■■..■■■■.■........■.....■.■te■aa■a.aO..ae..l..■..E.■.E■.■ ■ ■■■..!!.l■EE.e■eet■.eeet.Ome..ea■a■nnln■ ■eE.eae■O■OOEE■■■ mommolm NUNN MENNEN CCC..Cn■e.n■eee..mOO■.nnO■. .■.■■. .......■.........■...■. ■■.C...O■■.■OO.000aa■■Oe■al.n:e■..■■.■.■nett..■■■ Oman■ ■■:�■ monomma INN ■■..■...■■■■n.■■■■■■■...■E..n....t■.OeO.■O■.Oeaee■e aa■■.oe■ ■ ■.nmOtt■■aSae■.aE.!■■E.EE■ ■■■■■■.■■■nee■■■■■■.n■m..an..n■■ ■ ■■ ■.■■■■■■■■e!■!■E.EEO■■e.n..et..00t■.■■■aaO.nO.an■■m■ naOrr■■ ■ �i.■...t...■Oa■ton■■..■■■■O■■E■■a■■■■.eeeaet.a.a■..m!!OlOEnC■■■.■ ■ ■■Ot■■.■OnaenaEO■EOEO■.OEO■■ ■eO.O.■.......a...O.■■OOs SOMME ■ ■ C■■■COOO.■sa!!l.E.■EEE..■...�i:■■OOn■m.Oa.m.■■■...■E...■.t�■E■■ ■ 8■ ■ ■ ■■■■m■■■■■■■■■.■■■■.■.■■ ■n■ea■.OPn■n■a..m■..E...n.■ ■■.■ ■aa....■........■..■met■■�i■■...a..O.O...........■msam■ ■■ ■n■■■■■■a■.■■■■■m■■aaaaa■rear:■a■■■�t...........E.■■tee■e■ ■ ■■■!■■■...■.■■■■■■t■..■■OnrAre" ■■l�r..E..tEE.s.■.t■Oe..■ate■ ' ■ ■■ ■■....�iiOmO■■■�rt000■0�1��;■■a■u�ii....ee�iis.e■.t�i■.t■■t� a■ : C....................Orn■ ....e.i�.............■.■t■.mnO■a.■■ ■ nem■E■s■■■■■■■■■ntO�ea■��■S►�..e►v■■.eeet■n■■.eteeeO■ ■■:■OO■■ ■ ■ ■ ■.■■■.■t■ntO■■On■■O■■Oliu��.E�i►�,n■eE■e■OO■e..■tet■tesmOe....mO■ ■ ON ...■0....0■ea■■■...e.■ciu•■ rrrEe■Oes.00e■O.■■...em..■■O■..e■ ■ ■■ t ■■■■■tN■■.■.■!.■■E■■..■i�0i■.■M■.e.tt.■■/■■..e..■■.■.../■.■ ■ ■ ON ■■■■■M...■..■.■....■■e■■ale■■//////////......e.....!■.■■.■■ MEMNON ■m■ ■O■O■■O.O■■O■EEE.■■■eenrt!■■■t:�immts■.........0■EO■■O■■OE■■■O■ NM ■O■ CCOO■a.O■O■O■EEE■■E■■et��t®■■■t■■■ne.iri.E.!lneE■e.■■■■O■EE■te■E■ ■OI a ■.■■e.■■■■■O■■OO/■■e�in■■...■■■../�■.....■■■..■■■■..O■OOe000 ■: ■■ ■■■■■E■■EE■■■See■■ecce■e�"----.....-,........��/!I�■n.O/.eO./.■O. ■ ■■ ■..EE...nE■■See.■e......a■erg■ ■■■Er:■■.!llll�ef/�I■►1■t■■.■■■■.Ori ■ ■ ■.■..EEE■■■■■■■■■.....■.■.■!■■■■■'/■■■■il�/t��l�l►I�Ct1Yi7■■■■ttit■■■■ ■ani ■■■■.......■■■m.■■.■■Ot■.......t.�.m..mtet■IaOi�■'.....e■....■■ C.■ ■■..■e■■E■■O■■■t■.■■...■O■■■■■t�;��ie■t■ett■►satra■nOO■O.naa..!■ min ■ O Ona■.�t■■■■■■■■e.■....■.■..00■rim■Ou�i■.te..r>..k�eesee.eOOe.O■■ ■■■ ■ ■■n■:_■_r■--.Ott.■e■e.■■EOOEEEEEOrnear��».�Ott.m.�i■..�i..........■■■ ■O.�EC■E■■■■■.�i:,l■Ii.•...........�..itiy 7�1Jf/.......i.../t............. ■■■ ■M■E■M■../nae\.1■\''►�.■..■■■.■ ■■1:a■I■....e..rl.r►1.�.....■e..■■.■ Nsoon ,i Surveyors Certification Surveyors Certification for Subdivision Planning Department / Review Officer Davie County Register of Deeds KENNETH L. FOSTER cert to one or more of the KENNETH L. FASTER fiY GODBEr ROAD fa.ru,rd tfb vb► drove�,�. Proteeeiorwk Land Surveyor, Number L- � following an indicated by on x Final Subdivision Plat Approval Plat Registration ell ° A � ^h OA {�Q�°" '� I" X A. That the plot is of a survey that creates a subdivision of land within the area of a county or municipality This a b ayh,*0 � 0� the )eon Od Ws rdb d pedis as a*Wolsd eres@6 1:10,000 fed; Plot hos on ordinance that regulates porceh of land; raoadrq rsr[,risrnarta d tM FRO MR REG STRAMN U —_.._—.____-- -- tytiOCx _.. __ r two ti Old R in aoeardsrpo oft S 47-JO a oneerdsd. B. That the I; is of q wrvray tMwt is l000fed in wch portion of a county or municipality '�'r"'t 0n1"°'0' bb*`j"X01'for 0a"' QO1A4. as o an ordinance that parcels of land tIr Mty that is unregukated regulates I, — ftdw Mw d De*CPA*. wtlly This In Doy d 2W$ \\ \ willi�' "n scot G. That this kat is of a - p saucy of an existing parcel or parcels of land; 114 the rrew « pat to Shidr tteb artlfication is aMird rewib dl sldut«y OW,SM In Pent go,,, � . \ i L-2552 t). That this plat h recombination a survey of another category. such as the retombinatioof exist" parcels, o :out r'aprdnanab krrsoordM• rofessional Land Surveyor License Number ordered survey or other exception to the definition of u subdivision; a MWFFF PW R�rr a D� % \ US HIGHWAY 64 - E. That the information available to this surveyor is rich that 1 am unable to make o determination.to the best TAir the_ .-lC.fK of N�uNG 7!108 o/ professional abil' as to Day _-------- �mv p / provisions contained in A through D above. ?lsrr � _ _._ Day at .__ --. _ ._ Mr>F r>,ysrstant ,/ Deputy DAME COUNTY—NORTH CAROLINA / L-25� DAVIE COUNTY. NORTH CAROUNA ,`, SIPAUrr - ._----. .-- ----__ ___-- _.-_-- DAVIE COUNTY, NORTH CAROUNA C A R" " Professional Land Surveyor license Number DA�iL I,OuNTY NORTrl CAFtj it.,' ;NiFAS-IAIF NI,HwAY 4n ^\\ �. / 1Tff Z = SEAi_ _ -c� � L-2552 - r I l \\ Ff location Map -- Not To icale IM, 744 6 4 PU&JC R16Hr OF WAY HOUSE / ! N Sg C6159�� F (, r,—N p � TP inN.r)kp /V ANUN, Ur torrnar/y FDW)V P 9(A9FIP7,grW �►'' f EXISTING ACCESS EASEMENT 1Z j 16/ r ~ / r I -�----- PROPOSED 30' ACCESS AND U11U7Y EASEMENT . Now Or Formerly e ._ 1 ,t(JSEPNINE L. AIcC�4Allt'taGk' l it �t1'(�t.f Ji. 30' AC(YA'F4fZ:'r% PR 4?8 P(,' 417 _a / E a r, "� TR 'T `n e ) ACRF`� s �o+� PAKT 0- fkA(,1 ry Control Corner NIP 69. si"uc " 14 - _ _ -, � .. "sly , p:S,'��' W ��`'�,.. S oa�2114' ~ rrcAc;rr Ivu. 6 719 S •5q 5?' �»�` ExrSTiNG 1 , (b.11UU �-1�REb r F r,;T,r," `� 06'`��'�• "Ip SEE SURff' BY KENNETH L. FOSTER, PLS a _ 9 5' TTP [Y.�linp• _. - _. .. Y ,.,� � ; •!"'f i �1 h ,. .0 � ; 'i� t Fur iRUN i 1 Now Or 1-ormefyy ,n, `— EXISTING 30' ACCESS EASEMENT I t ^' Mow Or ()rme-r/y OB 2t1 PG 465 a, 06 U66 PG 46U 1 FiORREST W. BRYANT { , 114T(' ED APEA rO OF ABANDONFD_ on 1 (J:) JAG 06, �0 i __ ----»�--- 1 1 _ N 11.40'SO' E _ � � � \ 1i ` �_ - - -a `—r. •"114: i U H F ASEMEN1 A _; � _ tXIS1;NG 3�r_ nrCF�S f 1 /Yow a it forfneiy w ' IAWPFNrr t% 0?ANf7'/ , "t OB 388 PG 243 ? ut".pF p IYILLAM DOUGLAS GROOMS T i 1 CvLiLrul LID Now Or lorrnelfv Corner 1_ o CAR N YN /ATk4U l YFRL Y t 1 v OB UZY PG ,1,34 1 f- HF;CORI) I'LAT FOR f 1 0iJ1ll s ANti it 1 `ORAL 4 A 1 L 0,&Z L rS01V i Li Reference Deeds DFFD BOOK 438 QArF 744 IBGEND 1 PROPERTY LIPIE. v LIP EXISTING IRON FOUND Being A Portion Of: N300WU0b i 0 NTF SiW 'AF FI ilMl _T t —————— LINE FROM DEED OR PI-Al V PUINI ( NU Mk"4LN1A11UN ',,L 1 1 l'.AI.AHAN TOWNSHIP / DAME COUNTY, N.C. i rA,F NOV C]H FORMEPT r n, wDnT PTGMT nr VAY Nr1NlrMFNT DATE: APRIL 3, 006 SCALE. ;." 100' cv UB DEED BOOK 9 Lx1'o"Ir4G v' rwlL Pn l0 ri PAG£. FXlSTTt4r r,Q ANITF KMl1MFNT 2 FLAT Bock r L i `, TOTAL ACRES BY DMD - 2 005 n. DMD DOUBLE MERIDAN DISTANCE U � ILIT ML T EE GRA 1 e 111�_l I LC A L li UTILITY POLE X�'NN�,�'ff L �'OST�R d� �AS.SOCI.�T�'•S' �� �l i:F NTEP.l IN4 PL PROPERTr LINE ,�, ;„, +,1„ R/V RIGHT OF VAY ---_ _- PROFESSIONAL LAND SURVEYORS - PLANNERS ?P00 'MAS CRFFK PARKWAY SUI TF 1-B wINSTON-SALEM, NORTk CAROLINA 27103 ; ci -� NO GEODETIC CONTROL MONUMENTS FOUND WITHIN ;� � :,.� rFL_FPhfONF, '436 / 7?9-8350 2000 FLET OF THIS SURVEY Finch _ 100 ft -- --- SHEET i OF 1 JOB NO: 3162- 06C t Davie County Health Department Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville,NC '27028 (336)'751-8760/Fax(336) 751-8786' July 10, 2006 Mr.Heath Grooms US Highway 64 West Mocksville,NC 27028 Re: Site Evaluation:US Highway 64 W. Tax Pin#: 5729-14-0060 Dear Mr. Grooms, As requested, a representative from this office visited the above site July 10,2006 to perform a site evaluation. Based on the information provided on the Application for Site Evaluation and after the evaluation was completed,the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. 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 revocation if site plans or the intended use change. Improvement Permit f System To Serve: Wastewater Design Flow: System Type: ❑Conventional ?!Kccepted ❑Innovative ❑Alternative ❑Other System Location: Valid: 05'Years []No Expiration Site Modifications/Permit Conditions: —'ea"'W4 r"o, l�[� Environmental kealffi Specialist Date ps-i.p.letter 2/06