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336 Ketchie Creek Rd ' DAVIE COUNTY HEALTH DEPARTMENT � ° Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 - , Account #: 990004070 Tax PIN/EH#: 5716-29-3211 Billed To: Jason DesNoyers Subdivision Infa Reference Name: Location/Address: Ketchie Creek Road-27028 Proposed Facility Residence Property Size: 5.469 ac. � ATC Number: 4489 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST BE ISSLJED 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 CONSTR C ION IS VALID FOR A PERIOD OF F YF, . Environmental Health SpecialisYs Signature: ' Date: � �� Z� 2a� CERTIFICATE OF COMPLETION � **NOT�** 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 far any given period of time. A�IL��� / ''Z� Ql'lC�C L��;J�.I�w � _ Ii�.9 g ��- . `ti , V `y [ G 3_ �� .�,D. �,�� s-is��� � No t! ��t�usc �� � (� ��-� ' �,� �,.,,; �`' �•, � 3 S ic S lled By: ta r��`� �!.-� Environmental Healt p ' ist's Signature: � ate: � � � I' ' f � DCHD OS/99(Rev - cL� N�J \�...,.�v � DAVIE COUNTY HEALTH DEPARTMENT � ` ' • Environmental Health Section � P.O.Boz 848/210 Hospital Street � � Mocksville,NC 27028 ��`� � (336)751-8760 �� IMPROVEMENT/OPERATION PERMIT Account #: 990004070 Tax PIN/EH#: 5716-29-3211 Billed To: Jason DesNoyers Subdivision Info: Reference Name: Location/Address: Ketchie Creek Road-27028 Proposed Facility Residence Property Size: 5.469 ac. � ATC Number: 4489 **NOTE**This Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater system. An ALTTHOWZATION 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� Dishwasher: �d Garbage Disposal:�Washing Machine:� Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ � Desi Wastewater Flow GPD `� Site: New� Re air❑ Lot Size Type Water Supply�`l gn ( )� p . �� System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width��Rock Depth� Linear Ft. �1�a Other. c��G�/ �w+l�J Y:�'V v-'t, Required Site Modifications/Conditions: As s�tate��15A NCAC 18A.�.9l3�(5) �� � ���� e use IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S)IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis 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 3G)751-87G0.**** S%� �8 � ���, '� . ��,,�� Y � � s � 1 � � �'n''- �� `� � � � � � . , , � � ; Environmental Health Specialist's Signature: Date: DCHD OS/99(Revised) .,� � �A�P�,I� OR SITE EVALUATION/IMPROVEMENT PERMIT & AT ��� Davie County Health Department ` ' pUG 1 4 2�6 Environmental Healtla Section P.O. Box 848/210 Hospital Street ��pRppi��Et��A�NfAITH '" Mocksville,NC 27028 p�.���EC�uN1Y (336)751-8760/Fax (336)751-8786 Application For: ❑ Site Evaluation/Improvement Pernut ❑ Authorization To Constnzct(ATC) Q�oth ***IMPORTANT***THIS APPLICATION CANNOT BEPROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for inshuctions. APPLICANT INFORMATION . � " Name to be Billed TASo� 1�5N��yF.f25 Contact Person ��5�� �ES/�oyE�s Billing Address 33L KP�l,�iC �re�K Home Phone 336- 2�6(�js City/State/ZIP I�I�oGkSV/Ll,E , NG 270� • Business Phone 336- ?�'��s Name on Pernlit/ATC if Different than Above Mailing Address City/State/Zip � PROPERTY INFORMATION . NOTE: A survey plat or site plan must accompany this application. (Pernut is valid for 60 months with site plan,no/expiration with com lete plat.) Street Address E G�IE IeEE C�. City :. 1//GGE Tax PIN# s�16 a93�// Subdivision Name /) G'Z Section/Lot# —�—Lot Size ,5: �{6 C. Directions To Site: �j�o/17 ✓LLE dIC 6 /Q/�-Kd o G �e CrC �C TuR� LE T oGGocJ �c NO�R LAR6E ot.�E L u E S c.L B E /o�o �✓ GEF'f Date HouselFacility Corners Flagged -/`v- If the answer to any of the following questions is"yes",supporting documen�ation must be attached. Are there any existing wastewater systems on the site? ❑Yes [➢3�fo � Does the site contain jurisdictional wetlands? ❑Yes � . Are there any easements or right-of-ways on the site? ❑Yes Is the site subject to approval by another public agency? ❑Yes �� Will wastewater other than domestic sewage be generated? OYes LD�No IF RESIDENCE FILL OUT THE BOX BELOW #Peo le #Bedrooms ,3 #Bat�oms 2 2 Garden Tub/Whirl ool ❑Yes o _ _ Basement: ❑Yes o Basement Plumbing: ❑Yes �'No p IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business 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 ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: �. County/City Water lg'New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes [4�No If yes,what type? Tlus is to certify that the information provided on this application is true and conect to the best of my knowledge. I understand that any pemut(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 1 am responsible for all charges incurred from t/iis application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with appli�able laws and rules on the above described property located in � Davie County and owned by ASo� f $ALL�Sit/6yr,CS. —jT Site Revisit Charge P erty owner's or o r's 1 present ve signa r - Date(s): p8�1�0 6 Client Notification Date: Date �HS: Sign given ❑Yes ONo Account# �V Revised 2/06 Invoice# ' ' ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � ` � Soil/Site Evaluation � � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004070 Tax PIN/EH#: 5716-29-3211 Billed To: Jason DesNoyers Subdivision Info: Reference Name: Location/Address: Ketchie Creek Roa�7028 Pro'osed Facility: Residence Property Size: 5.469 ac. Date Evaluated: L .� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut � FACTORS 1 2 3 4 5 6 7 Landsca e sition • Slo % HORIZON I DEPTH � Texture rou Consistence Structure Mineralo ' HORIZON II DEPTH �, Texture rou - Consistence ' Structure / � Mineralo - � � HORIZON III DEPTH ' Texture rou Consistence Structure Mineralo HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE , �._. . . : .. �..��.� SITE CLASSIFICATION: ,�� EVALUATION BY` LONG-TERM AC C TE: � � - OTHER(S)PRESENT: REMARKS: ` . LEGEND T.an s ne Pocition 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 T�ctuTg : , 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 D�1St VFR-Very friable FR-Friable FI-Fum VFI-Very firm EFI-Extremely firm � � NS-Non sticky SS-Slightly sticky S-Sticky VS -Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic a�L►istlit@ SC-Single grain M-Massive CR-Crumb GR-Granulaz '� ABK-Angulaz blocky SBK-Subangulaz blocky PL-Platy PR-Prismatic , Mineralo�' • 1:1,2:1,Mixed . �tcS _ � 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 Classi�cation-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gaUday/ft2 DCHD OS/OS(Revised) ■��■����■��■■�■���■■■����■�s���■���■�■�■■e■■����■�����■��se���■��■ ■����■�■�■�■■����■�■���■�■■����■ ■�■��s�■���■■■�■�■������■���s��■ ■��������■�■�����s�����■���ee�■��is�■��0�■����■�����■■����■�����o■ ■������■���■�■������■�■��■����■■■�e�■■����v■�■�■■���■�■���■����■�■ ■■�������■�■■���������■■����■■■■���■�■��■�����■����■����■■�■e■���■ ■����■■■�■����■��■■�������■�s��■������o���■■���■�■����������■��■�■ ■■��■■�■�■�■■�■��■������■���■��■�������■�������■�■��������■■�s■■■■ ■�����■�■■��s�������■���■��■��■�■�■■�■�■�■�■�■��■��■�����■■��■■■■■ ■�■�o■�����■�■o■��■�■■■����■�■��■��■�■�����■����■��■����■■■������■ ■■��■�■�■���■�■��■���■�■�■■�■��■ ■�■���■�■e���■�■���■�s■�v����o�■ 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■��■��■�����■■������������■��e■■ ■��■���■��■�■�■■�����■e�■■�■������■�����■o�a■���■��s��■���■������■ ■■����■■�■����■■����■���■����■�■■��■■���e�o�o����■����■����■�■���■ r i \:;.` y � "- I hereby certify that I am the owner of the property ahown REVIEW OFFICER'5 CEFtl'iFICATE Filed for registrotion at o'clock M. � �� d and described hereon, which located in the County of Davie { �- � that I hereby odopt this plan of subdiviyion with my frea conaent, �, , Review officer of Davie County, � ' g ,� 2006 and recorded in � y,/� � � established minimum building setback lines and dedicate afl streets, certify that the map or plut to which thia certification � E � alleys, wolks, parks and other sitas ond easement to pubiic or is affixed meets �II stctutory requirements for rocording. 3�� i 1, �o ' ' � private use as noted. Furthermore, I hereby dedicate all sanitery Plat BoOk 8 Page `� � ' • sewe and ater lines to the County of Davie. � � "�' �" a — -�: DATE � , � �j ��- t � '� Fltln9 tee ; patd. M. BRENT SHOAF - DAVIE Co. Register of DeeGs � i ��;:\ � � , � � REVIEW OFFICER DATE � - = 1 ` � ° � �" �"''� ,^ j ° � OWNER � ��� o � � by `'� � � oEPurr—nssisrA�r �� � \ OWNER � � � � � � � s ' � � _ \ �� I � ...�. ..� � \ � � ` ,Y `��A�' ,'�yj a _. � \� ���.�.�` A'Aj 100' EXISTING POWER / / I �""""" '°�""` L # A � .9� LINE EASEMENT / , / I �� � TZ \� 9���' � ��'o BOBBY D. KOONTZ � . �. � -- . _ . ._ . __ JUDY ANN KOON � v,�� o D.B. 105, PG. 256 � �, - :� -.� D.B. � 05, PG. 257 Fo�, -� � �� � .��� � �;c r���,o�,�� �-''�� . ! �• i / � ��'�/,�• �Guh`-„ ' ..�^; �`'•� �� �� i' � � ,• �/��,�N /' � ._�_____ _.- -------�-- `.. . - r � � � Oj. � � i � � � i P� � �• � � _ _ � GAV�`c COUfV�i" P'.A�'������� �i;,��:.,;;� � - - - -- - - - -- -- �� � / � ' ' / I I � C T I E) new , I S 80•24'S3' E �ron � ,'" , ' —� � -- - - -- - -- - - - : ex�stinq R/R 557,50 , , $ 8 '2 ' 3' stone � gp;ke �� road �� � �� � � seo.a� ; LEOLA K. CARTNER ��� � � �� D.B. 76, PG. 1 � 0 j � � ' ��' - � � � D.B. 57, PG. �80 � � � � �� . � . _ � _� ' �,� �� � �� _� � �FtP� �' � / � n ' / �''y /� � /� < � S � _ � ' , . i'� � � / / � W � i' , / � � � sn I �� �• ' � r. i ' / / � � � �� �� i i ' cy n i � � � � . . ��� � � � � . � _ � AREA= 5.469 AC. � � d �j y i i �' COMPUTED BY D.M.D. '2 � � � �� �,,'� � . / � • � a � � R ONNIE H. RIDDLE � �/ �u / � / � � ' � . : /r/ t�;l�s �r+ Artl D.B. �24, PG. 483 I �� ,���';��2 �. � / reba r n /�� / \� / / �. i oo/v' s`)lS' � ' ` � 1 � . �E� � �0 ,��2 � � � � .- �� S�' �h , t� �. � ��W `� ��on � � t .' - � '"' � � i �� � 1 \� ��r � �ONNIE H. RIDDLE , /� 3�,00°0/ /-' �� �� NOTt: D.B. �,24, PCr. 483 � ��j�' .� w �9 g0 0�� W /� \ �. PRIVATE 'NELL & SE'r't�� _"S�� ', ! � ,� 6 ��5 / � 2. ' LOT TGTAL Or �.469 ,AC. i �• � bk� / 3. ZGN�Q RA � /� � � 5 � 4. NO NCGS MONUMc_NT '�VI � t .� � ' N /� 5. THE DAVIE C0. '-i� �'v"� ' � n� 4 ne c�i d�. New PRn�oSEo so' S AL"H � ,.�i �. �, � EASEMENT AS OF JUNE-21-2006 Z � ;I G N��U�'E I S N U T k�Q ���� �'� � RECORDA710N Or i�i; '�_a'�. J"��:'`': A PE��11T HAS TO ��E G��f::tiT�:" ii��'��.:�: � A SEPTi� SYS7EN � I'� i �.,_L i' _ 6. ?HIS PARC�L IS LG�Ai�� �ti A +''�-�� '�'�J � � 7. ANY NE1ti' STRUCTU�� �����`��. -�.�.�u'� ,_�.-�.�i-'���,�. SHALL 8E AT LF�,ST 2' A3UV� FL00� �::���l��;,�;� � existing iron `�5�°�� � WILL��M ,�. ZIMMERMAN �LAT ���A 1': � ,.����;�;,i���-- , N 6�350.�62 � D..�. 1 s3� Pc. >z � R ONNI �' � � �-, ��. , jyT :� —, e^ /i �• J 'i �^`�e .. i o L 1 .� . .i '�.a. .L..��� . � : `;� °•'.�t_ _ ��;. �;,�, OWNER -------------- �: � _ . � - � ..d���, .�� � � '<z`va^ �� ' ', ..,� ._ - �t�NNI�. H. �!�a�A►.i:. ;:�=_.`, . ry ��� � � � � � �. .. �. ,_- �i ; — — — — — — — — — — — -- — — — ex�5t�n9 , 330 iC�TCHIE L:;�.E�o �Ci��°wJ �����, _ ,' I i ro n ��. �v L�"J ' ; 'J', "_ =. MOCKSVILLr, .� �_-;:;J ,�'; .;_ I(we} hereby understand that this plat is approved as exempt from the �33n} ��i2-72�; � - - , , , �, < ;= � Subdivision G���inance of Davie County. This is a family subdivision and , ; "'�,�} �: _, ,,:�:`� � OREN D. ZI�f11IERMAN, �I�'. � �s for the ex��us�ve purpose of conveying land among famiiy members � ''o,��::;;q�`°' D.B. � l�'j3, PG. � 'r � within the thi•d degree of lineal kinship. These lots/trocts sha�� not CALAHA�� JU�i���� il �`` rt � be used for :ne purposa of sale or buildin� development, either now or , DAV I E C�U 1�1 I Y, ��J I'�i i i'"�, �-r��V'�i , �r, in the future, exce��t for those family members. Additional approvals tHIS 1S A FAMILY EXEMP7 SUB-DiVISiON may be requ��?d by Davie County or its successor agency before any �Ai�;: J�S;•',,;-�i�ti;� , �, subsequent :.:.�!e or �uilding development may occur. � $Lry<,yor Certification for S�����9ion — Davie Co�1p�jLNorth Garolina ,L n :�.��� � �� � / —�� TAX MAP REF.: L-2, P�c ���.1��,�::;:., ::�.;:� � I, Grady L. Tutterow, Registered Land Surveyor, Number L-2527 ���s;2� �' i certify to one or more of tha following aa indicated by an X: SU�V�(tJ CSY: Owners Date � o, That this ls a plot of a aurvey that createa a aubdivislon of TUTTEROW SU�ti'�.',�arAl�i{�s *l��:`l�:<y.��: ! land within an area of a county or municipality that hae an I, Grad L. Tutterow, certif that this lat was drown • ; 107 NORTH SA�.ISBUR" ��Rl_L I ' ordinance that regulatee parcels of land; Y Y P J fs,�l7,er t�Ckn,iwleda.� ha my line41 fami�y members j b. That this plat is of a aurvey tr,at �s �ocoted in auch a under my supervision from an actual survey made . who will be c�inveyeci the new�v created family lots are: MOCKSViLLE, �C 2 i J2� ` porkion of a county or municipality that is unregulated as to an under my supervision (deed description recorded in i �� (336� 751-56� v 1 ordinance that regulatea parcels of land; Book " ; Page , etc.) (other);that the � � � +E � � LOt# , and � c. Th a t this plat ia of a surve y of an exlatin q parcel or boundaries not surve yed are clearl y indicated as drawn -- -� - __ _ parcels of land; from information found in PL. Book ^, Page - , N a m e R e l a t i o n s h i p 1" _ '0 0' � �_d. That this ptat is of a aurvey of another cateqory, auch as the that the ratio of precision is calculated as 1: +2Q.000 ; 2. __ � N LOt# , and 100 50 0 i u� _ _ -'C'U = �� reco m bi n a ti o n o f e x i s t i ng pa r c e i s, a c o u r t—o r d e r e d s u rv e y, o r t ha t t his p la t was prepore d in a c c o r d a n c e w i t h G.S. N a m e R e l a t i o n s h i p � other exce tion to the de f inition of a aubdiviaion; — �� �iT� - P 47-30 as amended. Witness my oriqinal signature, Lot and ��—+-- --� _�_,�-- -- --- � e. that the information available to this aurveyor is auch - 3. th4t I am unable t make a determination to the best o f m N , r Y registratio number and seai this da o f �L y Name Relationship ' ' —' -- J rofeseional bilit to ro i (one contained In a. through d. abovo. �� P y �.� A. ., 20G 4. _N_ _� _ � Lot� and SCALE 1�i r�E �^ , � � Name Relationship '` Signatur 5 25z7 � � r 5. _��N __ Lot{� FILE NAM�: COvRD. ��: ��r Su eyor r Regiatration Number (Seol or Stom(j) Registration Number Name Relationship KOON-BG1 RI����'� -��� -- �_���µ �J :�-._. 1, Davie County Health Department Environmental Health Section P.O.Box 848/210 Hospital Street Mocksville,NC 27028 � . ' (33�751-8760/Fax(336)751-8786 : � Improvement Permit August 30,2006 Mr.Jason DesNoyers � 336 Ketchie Creek Road Mocksville,NC 27028 Re: Ketchie Creek Road Tax PIN#5716293211 Dear Mr.DesNoyers, 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. System To Serve: Wastewater Design Flow(GPD): �i� alid: Years ❑No Expiration System Type: ❑Conventional �Accepted ❑Innovative ❑Alternative ❑Other Site Modifications/Permit Conditions: asn oq os�e �tew swa�s�ts paadaa�� � SQ6 ' • Site Plan ��`b�� �P �-��- ���� � ' As stated in 15A NCAC 2k3A.3.8t�9(5) eccepted Systems may aiso bQ used � '; �' �.. En ' mental ealth Specialist Date �� i.p.letter 7/06 ,