336 Ketchie Creek Rd ' DAVIE COUNTY HEALTH DEPARTMENT
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° Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
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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.
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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
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**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.
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Environmental Healt p ' ist's Signature: � ate: � � � I' '
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DCHD OS/99(Rev - cL�
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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.****
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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.
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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
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� 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)
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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 � - =
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j ° � OWNER � ���
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# A � .9� LINE EASEMENT / , / I
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� 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�,�� �-''�� .
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ex�stinq R/R 557,50 , , $ 8 '2 ' 3' stone
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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.
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� /� � � 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 �' � � �-, ��.
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� : `;� °•'.�t_ _ ��;. �;,�, OWNER -------------- �: � _ . � -
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� � '<z`va^ �� ' ', ..,� ._
- �t�NNI�. H. �!�a�A►.i:.
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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
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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 ,