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6753 Hwy 801SPhone: (336) - 753 - 6780 Davie County Health D partment Environmental Health Section RECEIVED P.O. Box 848 ,MA 210 Hospital Street EMAILED lea;Courier # : 09-40-06 Dft= Mocksville, NC 27028 — ✓!` ` f ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection .Fax: (336) - 753-1680 �'�7�Name: �ot he 4elfA) d (Home) Mailing Address: 419,—R-71 (Work) IhZ— W6L Email Address: eD00 �S �/V Detailed Directions To Site: -%-/A) V % Q / S IIS II • —• Address: Please Fill e'lWlowingJWQrmation Ahout-9me EXISTING Facility: Name System Installed Under: a�A Type Of Facility: Date System Installed (Month/Date/Year): /d —1 7 - 6 Number Of Bedrooms Number Of People: Is The Facility Currently Vacant? Yes � No) If Yes, For How Long? Any Known Problems? Yes rlo If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Poa / Number Of Bedrooms: Number of People Pool Size: o2O X `C 0 Ga/arSize: Other: Requested By: ��' ��%� Date Requested: For Environmental Health Office Use Only ved Disapproved rommenty A—" 'i-flO l�Gfi �v o G. Environmental Health Specialist;C. �'/%% 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 limi Payment: Cash Paid By: that the on-site wastewater system will function properly for any given period of time. Order nt:$ /UU-Uv Date: By: 2 W n, % a✓' Account #: Invoice #: �37z/9 d Ct'A Lj� o s�fF All data Is provided as Is without warranty or guarantee of any kind either expressed or implied including but not limited to the Implied tib' iti warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of U N� ' Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out Printed:Apr 03, 2014 of the use or Inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT r Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002814 Tax PIN/EH #: 5746-94-4525 Billed To: Stacy West Subdivision Info: Reference Name: Location/Address: 6773 Highway 801 S-27028 Proposed Facility: Resience Property Size: 11.29 acres ATC Number: 3493 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 CO ST UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Date: (9/� 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. Septic System Installed By: Environmental Health Specialist's Signature: Date: e!�6 :ly -ox DCHD 05/99 (Revised) e r, DAVIE COUNTY HEALTH DEPARTMENT ! 7 s Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002814 Tax PIN/EH #: 5746-94-4525 Billed To: Stacy West Subdivision Info: Reference Name: Location/Address: 6773 Highway 801 S-27028 Proposed Facility: Resience Property Size: 11.29 acres ATC Number: 3493 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of 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 PIANS 6R THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM. Residential Specification: Building Type ! l #People #Bedrooms_ #Baths /2 Dishwasher: XJ Garbage Disposal: G7 Washing Machine: 00'Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ i Lot Size Type Water Supply Design Wastewater Flow (GPD) S.W' Site: New -00" Repair ❑ System Specifications: Tank Size/�WGAL. Pump Tank GAL. Trench Wide Rock Depth ��f Linear Ft. l Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LA FINISHED GRADE. ****NOTICE: Contact a system between 8:30 a.m. to 9:30 a.m. or 1:00 p.n Y' - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW .ntative of the Davie County Mealth Department for final inspection of this 30 p.m. op thF-daypf'igstal ti . Telephone # is (336)751-8760.**** � 1� h j-tY Environmental Health Specialist's Signature: Date: 'g�`h�(�/�� DCHD 05/99 (Revised) Jur] `-CU UJ . 1 U: UYe! uelv 1 C uuurl l.`J' er]vr]Cd 1 6r] 000 101 0100 APPLIG TTION I SITE EVALUATION/IMPROVEMENT I'LlIMIT & ATC Li avie County Health Department nvfFonmenia/Nea/th Section Box 848/210 Hospital Street �U 2 3 2""" Mocksville, NC 27028 •' `", (336) 751-8760 *** MPORTAi W-A'V1EG&(AF'PL,1JC& TSN CA&WOT BE PROCESSED UNLESS ALL THE REQUIRED INF RMA xQN... EIS. Refer to the INFORMATION BULLETIN for instructions. 1. 1. Name to be Billed S6CLI WgSJ Contact Person Mailing Address 13S fb ny ( od Home Phone City/State/ZIP 1 ` lyGl V l 1 t -e Business Phone 6I0q OZ 1LJ . C___r2. Name on Permit/ATC it Different than Above .� Mailing Address _ v-3. Application For: ❑ Site 33valuation _—A. System to service: 91"gOuse ❑ Mobile Home City/State/Zip ❑ Improvement Permit/ATC ❑ Business ❑ Industry ❑ Other L�DoL'h L,-5- Type system requested: lY Conventional ❑ conventional modified ❑ innovative ,j 6. If Residence: # People: 4 # Bedrooms 3 _ i# Bathrooms Z /Z L`iDishwasher ❑Garbage Disposal L3F7ashing Machine ❑Basement/Plumbing ❑Basement/No Pluu0ing 7. If Business/Industry /Other. verify type I# People It Sinks # Commodes # Jhowers # Urinals t# Water Coolers IF FOODSERVICE: #i�Seeate Estimated Water Usage (gallons per day) _ 11 e.—'. Type of water supply: 12/county/city l� WelVA- ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yesiv0 v If yes, What type? ***1,11PO�( �Z'Li`f;i 9QT C0A1PLETETHE REQUIRED 11ROI'ERTY INI�ORMA-1'I014 REQuES'rla) BELOW. Elther a PLAT or SITE PLA 1UST BESURkIITTBD by the client ]villiTHIS APPLICA'T'ION. L_, ---Properly Dimensions: 11--? Dimensions: rr— 'Tax Office PIN: # �i t `t``7 5Z ,--Property Address: Road Name b b993 Aw V615 city/zip te. W G - 21� If in a Subdivision provideinformation, as follows: Name: A-- / Section: Block: r Lot: '--'NVRlTE DIRECTIONS (front h-ludisville) to I'll 0PURTY: 6Y-Aahy-n gG I r 3 indeS 0A, y2 I SI�, r —� 4 U tl�atc home corners flagged:Zp—�Lo13 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 (lie information submitted in this application is falsified or changed. 1, also, understand that I am responsible for all charges incu, red f,•ont chis application. I,1]creby, give consent co 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 neca:ssany to determine the site suitability. DATE `?/ / 6 k -SIGNATURE 8L au-fql� !a/I U THIS AREA MAY BE USED FOR DR-,t.WING YOUR SITE PLAN (Inclu all of th ollowing: Existing all proposed property lines and dimensions, structures, setbacks, and septic location Sign given Revised DCF (05103 Site Revisit Charge llalc(s): Client Notification Date: ERS: Account No. f Invoice No. 0 -n r UIOVV L —ttwqmn tv omw-mukj�Kepe. F� tom Factor:k Radl 0 -D 2 '9 d Du en§Us4Tra -V- .... ..... L.2, or yro syl IM 71, ft -n 0 flo0d, hdiAl multi sy'l j OW2 to L a. Multi syl • V A Find Adjoining Parcels J DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002814 Billed To: Stacy West Reference Name: Proposed Facility: Resience Water Supply: On -Site Well Evaluation By: Auger Boring PROPERTY INFORMATION Tax PIN/EH #: 5746-94-4525 Subdivision Info: Location/Address: 6773 Highway 801 S--27028, Property Size 11.29 acres Date Evaluated: & !2 � /?ice Community Public Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position Slope % 16 tii HORIZON I DEPTH L 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: o 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 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) ■■EM■■MEMM■U■E■ME■ ■M■ME■■MMMEMMIMEM■ ■■■■■■■■■■■■■■■■■N ■MEM■■■N■■■■MM■■■■ ■M■MMMMM■MMM■■■■M■ ■MMMM■MMMMMMM■■MI■■ ■■■■■O■■■■■■■U■■■■ ■E■■■■■■■■E■■■■■E■ ■m■■■■■■■■■■■N■■■■ ■■■■■■■U■UU■M■■■■■ ■■■e■■en■■■■■■■■■■ ■UE■■■■■■■■n■■■■■■ ■■■■■■■■■■■■■■■■■■ ■■■■■■■MEMEMMU■■■■ ■■■■■■■■■■■■■■■■■■ i i ■MENU■■■■■■N■■■■ ■E■■■■■■■■■■■■■■ ■■eeee■■■■■■■■■■ ■■■■■■■■■■■■■■■■ ■■M■■U■■■■eee■■■ ■■■■■E■■eeee■■■■ ■■■■■■eeee■■■■■■ ■■■e■■■■■■■■■■■■ i ■■■■ MEMO ■■■■ NONE ■M■■ ■ ■U■■■■■eeee■■■■■■■■■n■■■■■■■■■■■■■■non■■■■■■■■■■ ■■■■■■■■■■■■■■�■■■■■U■■■■■eee■■■■■■■Ue■ne■■U■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■�■■■e■■■■■■■■■■■U■■■■■■■Nee■■■■■■ ■e■U■■■■■■■■■■n■■■eee■■eeNU■n■■e■■■■e■■■a■■■■■■■ ■■■■■■■■■■■■■■�■■■■■U■■■■■■■■■■■■■■■n■E■■■■eee■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■U■■■■■■■■■■■■■■■■■■■■■UM■n■■■■■Nee■o■■e■■■■■■ ■■■■MIME■■■ ■■■■■■■■■■ ■■■■■MINE■■ ■■■■■■N■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■MIME■■■■■■ ■■■NMI■ 1' ■■■■■■mons ■■■M■■■■E■ ■eeee■■■■■ ■■■■■■■■■N ■■■■■■■■■11 ■■U■e■■■■RI ■■m■■■■■■11 ■■■■■■■■■11 ■■■■■■■■■■■■■■■■■■■■■ NEON ■■■■ eeee■■■■■■■■e■■Nee■■■ea■■■■■■e■■m■■■■■■■■■U■ ■■■■■■■■■■■■■eeee■■■■eee■■■N■■■■■■■eeeee■■■■ ■e■■■■■■■■■■■■eee■■■�■■■■■■e■■■■■■■■■■■■■■■ ■eeee■■■■■■■■■eeee■■ ■■■■■■■■■■■■■■e■■■■■■■ ■n■■■■■■■■Nee■■■■■■■■■■■UU■■■■■■■■■■■■■eee■■ ■■■■■■■■■eee■■■■■Nee■■■■■■■■e■N■■■■■e■■■■■■■ ■■■■■■■eee■■■■■e■■■n■■■■■eeee■U■■■■■■N■■■■■■ ■■■■■e■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■eee■■ ■■■■■■■■■■■eee■■■■■■■■■eee■■■■■■■■■■■■■■■■■■ ■■■eee■■■■■■■■■■■■■■■■■■■■■■■■■■■■■U■■■■■■■■ ■■U■■■■■■eee■■■■■■■nU■■■■U■■■■■■■■■Nee■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■e■Nee■■■■■■eee■■ ■■■■■■■■■■■■■■■Nee■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■Nee■■■■■■■■ ■■■■■■■■■■■n■■■■e■e■e■■■■■N■■■■eeeeeee■■■■■■ ■■■■s■■■■■■e■■e■■■■■■■■■■■■eeee■■■■■■Nee■■ ■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■ ■■■■eNee■■■■■■■■■■■eee■■■■■■■■■■■■■Ue■■■■■■■ ■■■■■■■■■■■■■■■■■■Nee■■■■■■■■■■■■■■■■■■■■■■■ ■e■■eNee■■■■■■■U■■■■n■■■■■■■■■■■■■■■■■eeeee■ ■■■■■■■■■■■■■■■■eee■■■■■■■■■■■■■E■U■■E■■■■■■ ■eee■■■■■■■■■■eNee■■■■■■■■■■■■■■■■■■■■■eeee■ ■■ MEN iii OMEN MEMO Parcel #: L500000079 Davie County, NC - Basic Estate Search Basic Search Real Estate Search Tax Bill Search Sales Search 6 View Property Record for this Parcel View Map for this Parcel View Tax Bill Information Parcel #:L500000079 Account #: 77610000 Owner Information ulldin : Tax Codes BXF• EST STACY F & WEST STEPHANIE J EM(753 Land: ADVLTAX - COUNTY T Market: NC HIGHWAY 801 SOUTH ssessed: FIREADVLTAX - FIRE TAX Deferred: CKSVILLE NC 27028 Property Information Township Land (Units/Type): 9.240 AC JERUSALEM [Address: 6753 S NC HWY 801 Deed Information Local Zoning Pate: 07/2003 Book: 00501 Page: 0817 Plat Book: Pa e: Legal Description PIN 320 AC HWY 801 5746944525 Property Values ulldin : 220 47 CCCC BXF• 29,37 Land: 6144 Market: 311 28 ssessed: 311 28 Deferred: 01 Sates Information No. Book Page Month Year Instrument Qual/UnQual Improved Price 00501 0817 07 2003 WD Unqualified improved 0 View Property Record for this Parcel View Map for this Parcel View Tax Bill Information « Return to Basic Search Page 1 of 1 oP�t� Davie County Web Site All information on this site is prepared for the inventory of real property found within Davie County. All data is compiled from recorded deeds, plats, and other public records and data. Users of this data are hereby notified that the aforementioned public information sources should be consulted for verification of the information. All information contained herein was created for the Davie County's internal use. Davie County, its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or implied, in fact or in law, including without limitation the implied warranties of merchantability and fitness for a particular use. If you have any questions about the data displayed on this website please contact the Davie County Tax Office at (336) 753-6120. 1.5.9 http://maps.daviecountync.gov/itsnet/View.aspx?prid=1459698 8/31/2016