1127 Joe RdDAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name eef� 4a c k
Telephone Number M- Z/o? ('
Address / 7 Wide- w.
Mailing Address (if different from above)
Email Address:
Subdivision Name
Directions 1a 1 t nl 2
Lot #
Date System Installed- �'" " GeV Name System Installed Under
Type Facility ,JLu rel H NTLber Bedrooms_ Number People Served
Type Water Supply W&/ Specific Problem Occurring J CI M40Cf :Oi s
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge.
Date Reason
Mail To: 60?$Ll;F f
N. C.
STATE OF .NORTH' CAROLINA, navip County.
THIS DEED, Madethh�h_dayof_ Marrh _1905-,byandbet."n Glenda Presnell Whitt
and Timothy G. Swing of . Davie County
and sure of North Carolina, bereinsikrcalled Grantor, and David Wayne. Harman and wife, Carla le W_ Harmon
Of - nal/ i a County and State of North Carolina, hereinafter
called Grantee, whose permanent mining address Is
WITNESSETH: That the Grantor, for and in consideration of the tum of Ten dol 1 ars and OVC-------------------------- Dollars
and other good and valuable considerations to him in hand paid b the Grantee, the receipt whereo(h hereby acknowledged, has given, granted, bargained, sold
mid conveyed, and by these presents does give, grant, bargain, aelt convey and confirm unto the Grantee, his heirs and/or successors and assigns, pretnh, In
Fulton Township Davie i e County, North Carolina, described as follows:
Lying and being in Fulton Township, Davie County, North Carolina and beginning at a p/k
nail found in the center line of N.C. 801, said p/k nail being the Southwest corner of
Duke Power Company, Deed Book 168, page 372, Parcel 61.01 and being the Southeast corner
of the within described property; thence with the center of N.C. 801, South 74 degrees,
04 minutes, 25 seconds West 371.01 feet to a,r/r spike found, said r/r spike found tieing
the Southeast corner of Troy J. Carter, Deed Book 171, .page 421, Parcel 62; thence with
said Carter -line, North 00 degrees, 54 minutes, 35 seconds East 700.77 feet to an iron
found; thence with the line of C. Kenneth'Munday, Deed Book 139, page 147, Parcel 61,
South 86 degrees, 21 minutes East 386.49 feet to an iron found; thence with the line
of said Duke Power Company, South 03 degrees, 59 minutes, 30 seconds West 575.68 feet
to the POINT -AND PLACE OF BEGINNING and containing 5:410 acres as surveyed by C. Ray
Cates on March 28; 1995.
DAVIE COUNTY e3-38-96
STATE OF
$80.00
RgUNA
Real Estate
f✓p
Excise Tax
VEEI) TRANSFER CHEC
kED
3-0-�i5 nv�
DATE TAX SUPERVISOR
Prepared by Wade H. Leonard, Jr.
The above land was conveyed to Grantor by See Book No. , Page
TO HAVE AND TO HOLD The above described premises, with -an the appurtenances thereunto belonging, or in any wise appertaining, onto the Grantee, his
heirs and/or successors and wlgns forever.
And the Grantor covenautt that he h seized of said premises In fee, and has the riot to convey the same In fee simple; that said premises are free from en-
cumbrances (with the exceptions above stated, If any); and that he will we rra n t and defend the said title to the some against the lawful claims of all persons
whomsoever.
When reference is made eb the Grantor or Grantee, the singular shall include the plural and the masculine shall include the feminine or the neuter.
IN WITNESS WHEREO*, The Grantor his hereunto set 6h hand and seal, the dayand ear st ab wrl s n.
(SEAL) (SEAL)
(SEAL) (SEAL)
STATE OF NORTH 1dAROLINA COUNTY.
1, otary Publk o said ey, dogq 6 ertifj tbat
gd1 'dam e'er,,,
Grantor, ersonsll a .
p y appeared before ma this day and acknow� edged execution of she fo Ing dee .
Witness my hand and notarW seal this a qG� day o[ '19 /—•�.
My Commission Expires: d P.ALJ
Ila
STATE OF NORTH CAROLINA COUNTY.
NOT PUBUC
1, a Notary Pub&TAdNIS yp�;� t@Q
Grantor, personally appeared before me this day and acknowledged the execution of the foregoing deed.
Witneu my hand and notarial seal, this the day of
My Commission Expires: - - - , N. P. (SEAL)
STATE OF NORTH CAROLINA, COUNTY.
The foregoing « rti6ute(ip of D=a St=d Nota> yr R thl i C nFrkn�i r. rp Mty
is (XV certified to be correct. This instrument was presented for registration this 30 day of 14arCh ,19-95
at k12 7f9fla., P. M., and duly recorded in the office of the Register of Deeds of- unty,
North Carolina, in Book. 179 Page -819L .
This the _30 •day of MU_ , A. D., 19..U. ,�,/�
HENRY L. SHORE By .1�ALtm C n t�.[XX�,s
Register of Deeds i.tanQGQ0WRcgistcr of Deeds
This Deed drawn by
•
,'4f,9f;'1by N'.... -+-,....r r-: .,, ...,, ,....s._.. w.c,.4ir....,r i ., y,. sr, s,.,-• ,r.+.y _
F � j r. _ t; � x
{aF<`
�Xo.;
AUTHORIZATION`NO: 0'9 9 8 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION '
Peanittee,s P.O..Box 848
F Name.+- Mocksville, NC 27028 Subdivision Name: -
-, Phone #: 704-634-8760
Directions to property:��- �`' Section: Lot:
—meq-- AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#9 - t'19 - 1
SYSTEM CONSTRUCTION
��
Road Name: o� �`c► Zip: Qb�
**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/Authorizatiori 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)
k. ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS. '+
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
✓i �. 9+i'w `wxJ,'t`I'�} i `( av � ;gsir•r4 PsY+"Er"*t��^'i'v� f� ��'.wrW �.yr, .t;i ttix='`'T'Y»t r,. -"'� F� ;:� '
�. rr•-v w. 7io �.t.•. '+"'�e..Y..r r;:-'^,...:..�:.--c...r f. ;.,..� ,.�-...,� n . rs.>r._ •C4+» 4..�
DAVIE COUNTY HEALTH DEPARTMENT' �� 0
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Per„g . ttee s ;
�Subdivision Name:
Directions t6property: Section: "`„ Lot:
�. IMPROVEMENT
PERMIT Tax Office PIN:#..-!12--�-�
`,. Road Name:"'' �� ., Zip; ') ,
-, yy r� ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE r
"�, ! PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE "qt BEDROOMS D-4— # BATHS # OCCUPANTS �_ GARBAGE DISPOSAL: Yes oto '
COMMERCIAL SPECIFICATION: FACILITY TY\P�E� #PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT S 1' TYPE WATER SUPPLY V' DESIGN WASTEWATER FLOW (GPD) NEW SITE ✓ REPAIR SITE
tl
SYSTEM SPECIFICATIONS: TANK SIZE ILM GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER r
REQUIRED SITE MODIFICATIONS/CONDITIONS:
_.P
,3
*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 (704) 634-8760.
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 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME
DCHD 05/96 (Revised)
*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 (704) 634-8760.
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 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME
DCHD 05/96 (Revised)
�IPLICATION FOR SITE EVALUATIONAMPROVEMENT
Davie County Health Department
/A �p`�a �•v Environmental Health Section
W"
r„'. P.O. Box 848
D,5"�� Mocksville, NC 27028
M (704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �A-r�yyxoo Contact Person 16A,3-, d LW a^1 dU ,) 4A -P— 'foo
Mailing Address J �a ` fid_ ?nC�q A Home Phone q 10 Ck
nn I S
City/State/Zip100 Business Phone `1 9 S g
2. Name on Permit/ATC if Different than Above
Mailing Address
City/State/Zip
3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATC 10 Both
4. System to Serve: [ ] House pcJ Mobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People—1 # Bedrooms a # Bathrooms P4 Dishwasher [ ] Garbage Disposal
M Washing Machine [ ] 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: [ ] County/City N Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes XNo
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***?PPCMOF THE PROPERTY MUST BE
SUBMITTED WITHAPPLICATION.
Property Dimensions: l X �' WRITE DIRECTIONS (from ocksville) TO PROPERTY:
Tax Office PIN: # S'7 6 - �_ - 205-1
_ Efl s I TD Zo En k0,4d (�; UHr�
Property Address: Road Name bt✓ ROA8
City/Zip PAy"CE c_ oo pa'6 0."1 lE' T L'0/ZiL'E�2 0
If in Subdivision provide information, as follows: 2oA-J `i-
Name:
Section: Lot #: ;
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
Represe ative of the Davie County Health Department to enter upon above described property located in Davie County and owned
by - -to co ct all testi g proced res as necessary determine the site suitability.
DATE %' - SIGNATURE Y
Revised DCHD (06-96)
THIS AREA MAY $E
• A .. � + rte.
• DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME Q 6-� �� DATE EVALUATED — y 1
PROPOSED FACILITY �� tj 1W'Q PROPERTY SIZE
SUBDIVISION `�` ROAD NAME �OSLWJ
Water Supply: On -Site Well Community Public
Evaluation By:("", �, Auger Boring_ Pit
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
S
Sloe %
<�i — ro
HORIZON I DEPTH
Texture groupL
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
'A
Mineralogy'
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
--
SAPROLITE
—
r
CLASSIFICATION
S _
LONG-TERM ACCEPTANCE RATE
XA.y
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS: xxso .
DCHD (01-90)
EVALUATION BY: \�
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
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