611 Liberty Church Rd Lot 3 DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
3 Mocksvillc,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT
Account #: 990002706 Tax PIN/EH #: 5811-58-5512.03
Billed To: Jeff Hayes Subdivision Info: M�54_0 NV--ifAr LST 3
Reference Name: Location/Address: Liberty Ch Rd-27208
Proposed Facility: Residence Property Size: see map
ATC Number: 4593
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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. �UQ-1
System Type: �� S.T.Manufacturer 5�iG'fi Tank Dater (G Tank Size
Pump Tank Size �—
System Installed By: Ecyl 31I 412- E.H. Specialist: a Date:
Le
(/Y
1
- � filed
DCHD 11/06(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028 r
(336)751-8760 Fax#(336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account M 990002706 Tax PIN/EH#: 5811-58-5512.03
Billed To: Jeff Hayes Subdivision Info: N\41>1� M61W (JDT 3
Reference Name: Location/Address: Liberty Ch Rd-27208
Proposed Facility: Residence Property Size: see map
ATC Number: 4593 Site TypeyXw ❑Repair OExpansion
**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 #Bathrooms Z #People Basement❑ Basement plumbing.
Non-Residential Specifications: Facility Type #People #Seats
,^,nn,✓, Square Footage(or Dimensions of Facility)
Lot SizeC. Type of Water Supply: E<ounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow J,CTank SizeJrAL.Pump Tank GAL.
Trench Width �� Max.Trench Depth Rock Depth Linear Ft. '�3U7
Site Modifications/Conditions/Othei-.,k ew 0" ,ti> 2sOo —9��»tc�
14 34tl�� rye
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760.
Com' �C7� ►z'
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PjZoP L4
Environmental Health Specialist Date: 14
DCHD 11/06(Revised)
E E
WFFL TI OR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
FEB — 7 2007 Davie County Environmental Health
P.O.Box 848/210 Hospital Street
` Mocksville,.NC 27028
ENVIROPIh^,ENTAL HEALTH' (336)751-8760/Fax(336)751-8786
Ogen}..COilf'ffY __
Application For: .EJ Site Evaluation/Improvement Permituthorization To Construct(ATC) ❑ Both
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***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 l Contact Person
Billing Address / 1,`% C S Home Phone
City/State/ZIP ? v } / Business Phone
�A6 .
Name on Permit/ATC if Different than Above
Mailing Address * City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged �� d, d* )
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit'is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name Phone Number
Owner's Address le,2 City/State/
Property Address 1 l�„� City
Lot Size :faTax PIN#
Subdivisidn Name(if applicable) Section/L
Directions To Site: b
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 [� No
Does the site contain jurisdictional wetlands? ❑Yes ®No
Are there any easements or right-of-ways on the site? �Ples ❑No
Is the site subject to approval by another public agency? ❑Yes &JN6
Will wastewater other than domestic sewage be generated? ❑Yes lallo
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms '5 #Bathrooms _ Garden Tub/WhirlpoolYes-6
❑No
Basement: ❑Yes ❑No Basement Plumbing: ,21'fles ❑No
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:. iWonventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: L 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 �-No
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 permits)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 hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or staking�thes, cility location roposed well location and the location of any other amenities.
Site Revisit Charge
Prop�r er's?Owner's legal rep sentative signature
Date(s):
D� 97 Client Notification Date:
Date EHS:
X7(3
Sign given ❑Yes ❑No Account#
Revised 11/06 Invoice# if
Oct 09 06 11:58a davie county envhealth 336 751 8786 p.2
ATION FORSITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Health Department
Vv Environmental Health Section
P.O.Box 848/210 Hospital Street
Moc
(330 8760/IFax(336)7f1- 8786
R ior: Si luation/Imptovement Permit ❑Authorization To Construct(ATC) ❑Both
V1V1-NNORTANr*'+THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION 15 PROVIDED. Ref_r to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed i Contact Person
Billing Address
A. Home Phone
City/State/ZIP � � Business Phone
Name on Permit/ATC ifDii erent than Above
Mailing Address City/Stat::/Zip
PROPERTY INFORMATION
NOTE: A survey'plat or site plan must-,..company this application.
(Permit is valid for
60mthh siten pirationwith complete plat
LStreM Ce. PlmSOM
etAddresF ty ' i
Subdivisiog Name n/Lot# y- o Size � -
Directions o Site:_ —.Jr/ � Yl /-O�
t:K
Date House/Facility Corners 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 Imo
Does the site contain jurisdiction,wetlands? ❑Yes rTNo
Are there any easements or right-af--ways on the site? ❑Yes Mo
Is the site subject to approval by smother public agency? ❑Yes t1No
Will wastewater othet than dotnc:i tic sewage be generated? Oyes EiNO
IF RESIDE CE FILL OUT THE E OX B LOW
#People _ � Bedrooms #Bathrooms Garden Tub/Whirlpool es No
Basement: JYesflAdo BasententPlumbing: ❑Yes o
IF NON-RESIDENCE FILL OUT':TIE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
#Sinks #Commodes _ #Showers #Urinals_
Estimated Water Usage(gallons per d.,y) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested: onventional [IAcceptcd Olnnovative ❑Altemat.ve ❑Other
Water Supply Type: County/City Water ❑New Well ❑Existingg Well ❑Community Well
Do you anticipate additions or expansions of the facility this system is intended 10 serve?O Yes ce.
If yes,what type? _
This is to certify that the information provi-ied on this application is true and correct to the best of my knowledge. I understand that
any permit(s)or ATC(s)issued hereafter ate 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 /understand that lam responsible for all charges incurred
from this application. I hereby grant right:if entry to the Authorized Representative of the Davie Cotutty Health Department to
conduct necessary inspections to jrmLnnee Zliiapce with applicable]Aps and s on the above described property located in
Davie County and owned by / !1 r ./l �f3 �/aAl'� /ItPNt
Gw _ Site Revisit Charge
Prop.fty owner's or owner's legal representative signature
Date(s):
_1,Z-0 Client Notification Date:
Date EHS: `
Sign given ❑Yes 0N Account# ! �
Revised 2/06 Invoice# `�� CZA
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-98- 00 140
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001933 Tax PIN/EH#: 5811-58-5512
Billed To: Martha Rollins Subdivision Info:
Reference Name: Location/Address: Liberty Ch Rd-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: 11
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring ✓ Pit 12 Cut
FACTORS l 2 3 4 5 6 7
Landscape position L L_
Slope% 3
HORIZON I DEPTH rj -49p g p
Texture grow
Consistence 5
Structure C_ L
Mineralogy7
HORIZON II DEPTH (p.
Texture group, L 5 •C
Consistence .C,
Structure
Mineralogy Ste. i
HORIZON III DEPTH z- l
Texture group 5;U•S S;C
Consistence ' S ^r5
Structure V L03 K, Att
Mineralogy5XW
Y
HORIZON IV DEPTH +
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS --
RESTRICTIVE HORIZON (1110 yo
SAPROLITE --
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE O• �� ,3 0. ,
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: �•7i7y OTHER(S)PRESENT: cu`F" �`1�
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
MOW
VFR-Very friable FR-Friable FI-Firm 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
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
Elvia
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 05105(Revised)
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Davie County Environmental Health
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT
Account #: 990001933 Tax PIN/EH #: 5811-58-5512
Billed To: Martha Rollins Subdivision Info:
Address: 1201 Wagner Road Location/Address: Liberty Ch Rd-27028
City: Mocksville Property Size: see map
Reference Name:
Proposed Facility: Residence
**NOTE**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,plat or the intended use change.
Permit Type: gRew ❑Repair ❑Expansion Permit Valid for: .® Years ❑No Expiration
Residential Specifications: #Bedrooms .2> #Bathrooms 2 #People Basement❑Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Design Flow(GPD): 7 Type of Water Supply: 26unty/City ❑Well ❑Community Well
Site Modifications/Permit Conditions: , �n��P ST�hjiQ:� ')`iBu
yl � 5�1� r'
System e LTAR
Initial L_�t-94urN-isC»+k
Repair
Site Plan
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O CYj•' r--------------------------- _ existing BEAR CREEK CHUR
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30' MINIMUM BUILDING SETBACK - ----------------- p
►+•1 UNC __ 25.8 E
A W I
-Oka -- DRIVEWAY FOR INGRESS/EORESS
"ti n i
1 TO LOT 03 SHALL BE L
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OCATED
rw ^ o o i IGT 3 SOUTH OF NORTHERN LOT LINE D —
v1 AREA��0,BY 998 AC. _ s esy3B• E NO SCALE
z I (INCLUDES SEPTIC EASEMENT B) I 30' 63.00 W
NO APPROVAL REQUIRED BY THE i (SUBJECT TO S.R. 1002 R/W)
JIBE COUNTY PLANNING DEPT.
M ; EXISTING LOT, TAX MAP, E-2, PARCEL 32 ; , -� N VICINITY MAP
NEW SEPTIC EASEMENT I t"1
1 SEE D.B. 059 , PG. 933 (tract 1) I I (B) TO SERVE FUTURE W
ZONED R-20 LOT 2 SEPTIC REPAIR .,
q L'------ ----- MINIMUM BUILDING S j r�up AREA. EASEMENT AREA
existing - E79ACK LINES --- I 618 REQUIRED BY THE DAME g) y
CAVIE COUNTY PLANNING DIRECTOR iron 99.89 9 - - ------
extattnCOUNTY
iron N 22,38 a --46....;..,_ I gl�° DEPARTMENTFORONSITE 20 PAVED
I N 85 57 24 W ----J' z1 WASTEWATER SUITABILITY. Iy
i-"- N 95.53'38• gltiattng 130,44 I Filed for registration of _. _o'clock M.
I I iron N 85, 5.3'38- W 89.63
REVIEW OFFICER'S CERTIFICATE I control ejiisstning 65.00
• eiront 29.48
TOTAL,• 184,11 , 7 area recorded in
1„ Review officer of Davie County, I S 85653'38,38' E� ng
c erti that the map or plat to which this certification
---___- .
Is a xad meets all statutory requirements for recording. Plot. BOOR Page
s
FIling fee # paid. M. BRENT SHOW - DAVIE Co. Register of deeds
REVIEW OFFICER DATE
by
I
CERTIFICATE OF OWNERSHIP AND DEDICATION i O
L__4 DEPUTY-ASSISTANT
I herebycertify that I am the owner of the roe shown I --- -
Y property ttY I - NEW SEPTIC EASEMENT
end described hereon, which located M the County of Davie (A) TO SERVE EXISTING
that I hereby adopt this plan of subdivision with -my free bonaent, - -- - I ENCROACHMENT OF ,1
establish minimum building setback lines and dedicate all ktreets, I SEPTIC LINES FROM H 7Si
clleys, walks, parks and other sites and-easements to public-or— I MURPHY PROPERTY
private use as noted. Furthermore, I hereby dedicate all sanitary
sewer and water lines to the County of Davis. I O I g' � LOT 2
1 2ST: DATE I p co I AREA= 0.898 AC. M " ''�
AREA BY DMD c
!n 13 (INCLUDES SEPTIC EASEMENT A) Cu
$ C�
LO ROLLINS ( ) I ,� "� I W TAKEN FROM TAX(SUBJECT TO SMAP E-2.1002 RPARCEL 31 y V ^t
M� av
TOLLINS -- -- I w I Z ZONED R-20 y OCz
N �+ X i UNMARKED POINT
CERTIFICATE OF APPROVAL OF PRIVATE
SEWAGE DISPOSAL SYSTEMS I . I d• ? NOTES:
I, hereby certify that the Davie County Health
Department has evaluated the subdivision
y' 1. 3 LOTS TOTALING 2.766 ACRES AVERAGE LOT SIZE 0.922 AC.
entitled : PLAT MAP FOR MARLO CORP. I b ( )
with respect to criteria and conditions established
b,y state law or promulgated thereunder and the 0 • 2. NO NCGS MONUMENT WITHIN 2000' OF THIS PROJECT.
I
is found to comply with such criteria and
conditions EXCEPT as set forth in such evaluation. i I A ( 192.52 totnt ) 3. LOT 1 HAS EXISTING DWELLING AND SEPTIC SYSTEM, WITH PUBLIC WATER
For details of this evaluation and for limitations, I 'Q, 155.69 E- N 88 40 30 K eironing 4. WATER IS SUPPLIED BY DAVIE CO. WATER SYSTEMS.
a-De the written report on file at said department. I I 36.83
existing 5. LOT 2 & 3 WILL HAVE PRIVATE SEPTIC SYSTEMS.
IMPORTANT NOTICE: THIS CERTIFICATE DOES NOT I iron
CONSTITUTE A PERMIT OR APPROVAL OF INDIVIDUAL I k'ELl W 6. THIS PROPERTY AND ADJOINING PROPERTIES ARE ZONED R-20
LOTS IN SAID SUBDIVISION FOR INSTALLATION OF I I f'�SSE
SEWAGE FACILITIES. 7. LOT 3 IS AN EXISTING TAX MAP PARCEL.
1 I o,
0 TE DA ER y
R R SPIKE
I 2.5' EAST PLAT MAP FOR.
. IZYEYOR'S CERTIFICATION OF C L RD.
1, Grady L Tutterow, certify that this plat was drawn I MARLO MANAGEMENT CORPORATION
under my supervision from an actual survey made I '"
under my supervision deed description recorded in z 1 DN�n,- OWNER --------------- -- DEVELOPER
Book 659 ; Page ,�,'�,3 , etc.) (other);that the je11 r 11e r,, ( „ � -
boundaries not suryeclare clea indicated as drown ��� CA ��� '
from information found in PL Book , Page ,�`¢ ,,,,,,,Rp''• � 20 PAVED , MARLO MANAGEMENT CORPORATION
that the ratio of precision is calculated as 1: +20 00 Q.,0 eESS/ ''•�� in
that this plot was prepared in accordance with G.S. . OF O 'tiy
47-30 as amended. Witness my original signature, �,:�QQ' ti I g 1201 WAGNER RD.
It-ones number and seal this .(� day of SEAL �i — — LOT y MOCKSVILLE, NC 27028
�A A D. 20 7 - L-2527 _ `'_�' existing AREA= 0.870 AC. 336-492-7505
%^- Iron
;('t -:< '� ` `. control v
SUN Or _ corner AREA BY DMD
Q A p (SUBJECT TO S.R. 1002 do 1320 R/W) C LA R K S V I L L E TOWNSHIP
(Seal or tamp License Number �9O sURV,,.•�!!'Q.,�• R s 7�,Ct�P� g TAKEN FROM TAX MAP E-2, PARCEL 3, DAV I E COUNTY, N 0 RT H CA R O LI N A
032 ZONED R-20
� 71 �a
THIS IS A MINOR SUBDIVISION W TAX MAP PARCEL.: E-2, PARCELS 31 & 32
Surveyor Certification for SubdMslon - Davie County. North Carolina v
>n DATE: JANUARY 10, 2007
I, Grady L Tutterow, Professional Land_-Surveyor, Number L-2527 RO p0 cyi 1
certify to one or more of the following as indicated by an X: c SURVEYED BY:
,..X _a. That this is a pias of a survey that creates a subdivision of C•e�, '
y TUTTEROW SURVEYING COMPANY
land�int aunt area of a county or rnuniciooaty that has an S C 107 NORTH SALISBURY STREET
ordir'g"10� f °r I0"d' '�. ' ,�! N �'3c?9 MOCKSVILLE, NC 27028
b. That tt+ts plot b of a 3� C� c,3, (336) 751-5616
tav" Mat is located in such a 649 S
or i�of t � or npe all@ of liar is unregulated as to an t`
�., � 39, � W
rsada�t+u O'a'oMs �
"' •o SCALE: 1 " = 4b'
c. That tMs pot is d tawX. et err srdrtfnQ pr rcel or d
Parcels of "IF4 L -
d.
That this stat ie eel
recombination of arlIM erftsti+a '° ;,� Ouch as the ; . 40 20 0 40 80 ---120 -
other e>eWiI� N �M ll rw ., svrvsy, or . - _ _. _ _ t .N_. _--- --- - - - ----
__. _.
(
that I em unable to snake a determinatlon to the b4st of my °it
prof lona) ability • o provlslone oantalned In a. through d. above. SCALE I N FEET
00 COORD NAME: FILE NAME: DRAWING NUMBER:
- �- ,l ; BUCKJONE-68 MARLO 23506=3
Irmo Llcenile Number