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403 Milling RdHEALTH DEPARTMENT RELEASE a,.sv„Fv Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Zak Yarnot Address: 403 Milling Road City: Mocksville State2ip: NC 27028 Phone #: (704) 662-4183 For Office Use Only *CDP File Number 124252 -1 i5-000-00-067 County ID Number: valuated For: HDR/WWC PERMIT VALID 1 1 / 2 0/ 2 0 1 8 UNTIL: r Property Owner: Zak Yarnot Address: 403 Milling Road City: Mocksville State[Zip: NC 27028 Phone #: (704) 662-4183 Property Location & Site Information Address403 Milling Road Subdivision: Road # Mocksville NC 27028 Township: Directions Hwy 158 turn right on Milling Road, Property on left after Northridge Ct. 'Structure: SINGLE FAMILY # of Bedrooms: 3 'Water Supply: PUBLIC Basement: R Yes ❑ No 'Proposed Improvement: Garage # of People: Phase: Lot Type of Business: Total sq. Footage: No. Of Employees: It is the responsibility of the owner to maintain a 5' minimum setback between the wastewater system and any part of the structure foundation, including porches, decks, and any other appurtenances. If you are unsure as to the exact location of the septic system, please have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed. This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps. Signature Required?, QYes ONo Applicant/Legal Reps. Signature: *Date: *Issued By: 2244 - Daywalt, Andrew *Date of Issue:. 1 1 / 1 9 / 2 0 1 3 Authorized State Agent: AJA4;-�04� **Site Plan/Drawing attached.** Total Time:(HH:MM) G Hand Drawing OlmportDrawing 0 1 Hours 0 0 Minutes Davie County Health Department OV� ,pNiNvironmental Health Sectio CEIVEDC6• lP.O. Box 848 210 Hospital Street b it--�-(3Courier # : 09-40-06 tj Mocksville, NC 27028 _ Phone: (336) - 753 - 6780 Fax: (336) - 751 - 8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: �Gz k �cr ►' Yi o Phone Number (70 q) 6 _3_(Home) Mailing Address: 1)0.3 NI o l i Ng a,--(_ (Work) ILVIOC4k S V( t ac 2-,61 Email Z.XC =Y- )7 j21 , V Cx_0 l , On-? Detailed Directions To Site:L2 u !ate as S'--�- Ph /Vj r �� Rc� 2'ej s13(:�' Aq 7-7 r -- ch U Property Address:, Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): Number Of Bedrooms:_ Number Of People: Is The Facility Currently Vacant? Yes (° If Yes, For How Long? Any Known Problems? Yes ® If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility:�k—e7 aP Number Of Bedrooms:_Number of People__ _ Requested By: �,� ��l/'',. Date Requested: / l - 'jr-i 3 For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist 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 ' nited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash �Chec Money Order # Paid By: q Received By: !� . Account #:_ 12 L2. __Invoice #: d5% EGD IYZ07 D.B. 493. PC. 437 I kuwiy p.16y the 1 am M ewn.r d M .Mown aW d4EeTW.d kr..h wNk11 looamd h M Two e/ NacYwEw Mt l N••�Y Wapt 1kb 0lan d .IeaNdMw wlm my kw. aon.d, .Mak6Nlad tmlpa- tNlidi,q .smack 4 eb dddM4 dl .owal.. aH+eb wa0"'wE aopOwa n°i u. PwU awn, kw�0°Wiwa m �R«r 'q and w.tr. IM. m M Tow a WeFwW OMER OWNER LOT 1 tICLL"m SR 15M " LOT 2 INCLUDES SR 1600 R/W SC MEM ERaNSEO EA$TM[Nl -i ' 1 i PLAT MAP: / 1 PINE LODGE / l OedY L Tuttrew, owl6y MI ab plat wa hewn p 1 Nwq m�m�!' .Wr�bian hob m eomd vvy moa ' �MwwY.d ' / fau�ndada�i en�Il�W�a a n / .' :.. hem hfomatlan bund h PL Hem Pap. oat coat M ,e11a e< pncbam N eOweS3 .. Ml mb Blot ww p�wad m daoemm�ew wkn 0.S 47-30 m °maetlad. Illbr aq -41" dpwkae• ry nglwtr a ,wwrbr aW ..d tN. _jg aay d .•..,. - J ' AD. 200 LOVE ROWSORVXTING COMPANY =Y.FfS�.'T,'��"t• (sw« ad R.ywMoaw NumtMr TMS PROPERTY WILL BE SERVED BY PUBLIC WATER AND PRIVATE 1/OCKSNItlE. NO 27026 (3J6) 751-6616 : C . •t Y THS SIXNEV CREATES A SUMMSION OF VNO W M THE � .1 f tel. -ATEA OF A COUNT' dl MUNICIPAMIT' 71NT NKS AN REC PAROMS OF LAND. 50 23 0 50 100 150 ', rCy r Trw•' 7) ew0UNC SET-6ACRS: FRONT. 40' CRADY L OW, I" L-2527 X60 1 tc-�S Hc'H1'ET V w0 2N 4ts7A tmAL a uwE R_EYEW OFFICER'S CFRTmL TE l R.M.. efllvr d DaN. Ceuny, oinad a. map « pbt to wNeN ab e.rOGwmn b wM n.M, m MWMy Npu mwlb Tan nieani,i. 0a� oEFKrR DATE CRADY L. MOCLAMROCS D.B. 165, PC. 762 ZONED N/R CAROLINA CONFERENCE OF SEVENTH -DAY ADVENTIST, Inc. D.B. 76, PG. 430 ZONED NIB .~�awr�•IwMir�"r'kk° bib x,rA O+.r�.. M11[ MWRL .�A Y v1brY N a.r•M .,IIMy NY Mab Y. r a�.�niyep,! Mwr wM wd wl.�rOSFR a�'wwTM Mk b W�wMi+�Yw .b n.1w,Ma ti M .wbw.y a M aaMw ,o/Ml ti Ilmv, TNn mer.Iaia 900 nor CaNeTME A EOe.t at 0�2 Im OI Ilr AON TOR MHfNW1011 OF �.� .Z. !! 1 R_..t p A /7 1 FI.a Tar Nr.w6." d I—uo dadl ASI. 13 -.4 1 oF' 2004 an° —W In PNt Book T Pa. -v.8 PAOLIa>• E Hort BnlFflp-l/ - pA- k.°.V d Eri M -J MwsmP tVE LOT 3 DRS.IIDES SR 1600 " 1 ArWy awUlY eanWYwwlU MMp T1— SL OwPYbt adR.epwdw adrn :"W-4:1=411 "Wm wMAaaM La U1 :1=E ..y — h wdM miW{I. n aMi W o.N id d O�. MaY luraky�dndW "PP -0 m b6iet M^OOdI eppagp W nNa,dotlon daY oat hdudn tm end WWifnn Eery tamWw ae.w K k"do. awp AM M aonatrudb„ ^-K-7 of b AdL g s MN--h— ,nb M day d l 2D04 I o I "RI oar\ (4 4 �41w0 �N I ---------- I 4 PLAT MAP: �g 1 1 PINE LODGE C3'1 1 1 PAMELA S. ARNN 403 YIWNO ROAD M V 61I�Y (336) 413-4566 hY MOCKSVILLE TOWNSHIP ry DAVIE COUNTY, NORTH CAROLINA DATE: JULY 24, 2004 1 tc-�S Hc'H1'ET V w0 2N 4ts7A tmAL a uwE R_EYEW OFFICER'S CFRTmL TE l R.M.. efllvr d DaN. Ceuny, oinad a. map « pbt to wNeN ab e.rOGwmn b wM n.M, m MWMy Npu mwlb Tan nieani,i. 0a� oEFKrR DATE CRADY L. MOCLAMROCS D.B. 165, PC. 762 ZONED N/R CAROLINA CONFERENCE OF SEVENTH -DAY ADVENTIST, Inc. D.B. 76, PG. 430 ZONED NIB .~�awr�•IwMir�"r'kk° bib x,rA O+.r�.. M11[ MWRL .�A Y v1brY N a.r•M .,IIMy NY Mab Y. r a�.�niyep,! Mwr wM wd wl.�rOSFR a�'wwTM Mk b W�wMi+�Yw .b n.1w,Ma ti M .wbw.y a M aaMw ,o/Ml ti Ilmv, TNn mer.Iaia 900 nor CaNeTME A EOe.t at 0�2 Im OI Ilr AON TOR MHfNW1011 OF �.� .Z. !! 1 R_..t p A /7 1 FI.a Tar Nr.w6." d I—uo dadl ASI. 13 -.4 1 oF' 2004 an° —W In PNt Book T Pa. -v.8 PAOLIa>• E Hort BnlFflp-l/ - pA- k.°.V d Eri M -J MwsmP tVE LOT 3 DRS.IIDES SR 1600 " 1 ArWy awUlY eanWYwwlU MMp T1— SL OwPYbt adR.epwdw adrn :"W-4:1=411 "Wm wMAaaM La U1 :1=E ..y — h wdM miW{I. n aMi W o.N id d O�. MaY luraky�dndW "PP -0 m b6iet M^OOdI eppagp W nNa,dotlon daY oat hdudn tm end WWifnn Eery tamWw ae.w K k"do. awp AM M aonatrudb„ ^-K-7 of b AdL g s MN--h— ,nb M day d l 2D04 I o I "RI oar\ (4 4 �41w0 �N I ---------- I 4 PLAT MAP: 1 PINE LODGE OWNER ----------------- DEVELOPER PAMELA S. ARNN 403 YIWNO ROAD MOCKsmu. NC 27026 (336) 413-4566 MOCKSVILLE TOWNSHIP DAVIE COUNTY, NORTH CAROLINA DATE: JULY 24, 2004 LOVE ROWSORVXTING COMPANY I J'OTS TOTAL AREA. 5.7t7 AC. IM 2 AVG. LOT S12E� 1.906 AC. 107 NORM SALIS6URY STREET TMS PROPERTY WILL BE SERVED BY PUBLIC WATER AND PRIVATE 1/OCKSNItlE. NO 27026 (3J6) 751-6616 SEWER PYSTEM, 4) THIS PROPERTY ZONED N\R TAX YAP I-6, PARCEL 16.01 5 THERE ARE NO NCCS MONUMENTS SCALL` 1' . 60' W(TH6) THS (PROP RTY2000 FT' IS 50 23 0 50 100 150 WRH1N A pL000 AREAAS DETERMINED BY F.E.MA 7) ew0UNC SET-6ACRS: FRONT. 40' SCALE IN FEET REAR. JO' SDIE. 15' COORD NAME RLE NAME DIIANUMBERa GRADYMC-51 ARNN-PAM 104040 )-JA Account #: 990002741 Billed To: Pamela Arnn Reference Name: Proposed Facility: Residence ATC Number: 3468 DAVIE COUNTY HEALTH DEPARTMENT J Environmental Health Section P. O. Boa 848/210 Hospital Street (/ Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5748-47-1782.PA Subdivision Info: Location/Address: 1463 Milling Road -27028 Property Size: 5 + acres 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 CONT CTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Z�&2 Date: 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. tTf�'1G \n J rw Septic System Installed By: Environmental Health Specialist's Signature: j/ Date: DCHD 05/99 (Revised) t J , Account #: 990002741 Billed To: Pamela Arnn Reference Name: Proposed Facility: Residence ATC Number: 3468 DAVIE COUNTY HEALTH DEPARTMENT J Environmental Health Section P. O. Boa 848/210 Hospital Street (/ Mocksville, NC 27028 (336)751-8760 Tax PIN/EH #: 5748-47-1782.PA Subdivision Info: Location/Address: 1463 Milling Road -27028 Property Size: 5 + acres 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 CONT CTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: Z�&2 Date: 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. tTf�'1G \n J rw Septic System Installed By: Environmental Health Specialist's Signature: j/ Date: DCHD 05/99 (Revised) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002741 Tax PIN/EH #: 5748-47-1782.PA Billed To: Pamela Arnn Subdivision Info: Reference Name: Location/Address: 403 Milling Road -27028 Proposed Facility: Residence Property Size: 5 + acres ATC Number: 3468 **NOTE** This Improvement/Operation Permit DOES NOT authorize the construction of a 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 PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLIN SxS ir Residential Specification: Building Type #People #Bedrooms ^�` #Baths Dishwasher Garbage Disposal: ❑ Washing Machine Basement w/Plumbing: ❑ Basement/No Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size C Type Water Supply Design Wastewater Flow (GPD) Site: New. Repair ❑ System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth.,& Linear Ft. Other: Required Site Modifications/Conditions: Lel't IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this system between 8:30 a.m. to 9:30 a.m. or 1:00 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** i Environmental Health Special st's S/ignature: Dater DCHD 05/99 (Revised) • � uNno��lnva APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT ATC 11I1YMHNiNMNOH1AN3 Davie County Health Department Enviroamenta/Health section 1.1 AY 1 2 2003 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336) 751-8760 n (j na ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED �J �( INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed I (,L.M e ICA /—IT n Y( Contact Person Mailing Address ` ,Home Phone e4. `7 60 /,j /^ / City/State/ZIP "v �'1 S' 1// 1` l /1 , /U Cs Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: Site Evaluation Improvement Permit/ATC Both 4. System to Service: Hous Mobile Home Business Industry Other 5. If Residence: # People 1;z' # Bedrooms # Bathrooms 1z Dishwasher Garbage Disposal t/ Washing Machine Basement/Plumbing Basement/No Plumbing 6. If Business/Industry/Other: Specify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # SeatsEstimated Water Usage (gallons per day) 7. Type of water supply: C t1 Count /City Well Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? Yes No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. . Property Dimensions: .5-` - aey- s WRITE DIRECTIONS (from Mocksviille) to PROPERTY - Tax Office PIN: # 71 q! I"j a �• P 1�`� ©i-7' 1�Y4L.�' Property Address: Road Name as l M i I� i n d 1 City/Zip M O- Ks 11 I 1 -e- X70 5'' l.o -7- .5 If in a Subdivision provide information, as follows: On le Name: �7 l"� 7 LhAiq �V�/1 7 . Cf v. -e, Section: Block: Lot: Date home co;rstla ed: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits) 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 ani responsible for all charges incurred fi•oni this application. I, hereby, give consent to 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 necessary to determine the site suitability. DATE 5/%� / 4� SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). f60AY—it,c6Ac.L P(/-1�� V-0 l x. -ba e 7 1 S -It &,- -e ry"-tT Sign given t -'- Revised DCHD (07/99) Milttgl &J V7 Client Notification Date: EHS: Account No. i Invoice No.� / ✓ (15.26A) i M r F OF i nt (3.27A) (5.60A) 1 8783 1782 (3.78A) 4761 , , 51 , - 0-01, 10Isu9;v y . . . I I . . . . . . . 401 407 14 MILLING 200 ' y SR 1600 (1020) r r,: 140 4 6984 X282) � ri 142 0 r O 6774 42 7220 40 156 \` 1fig _ APPLICANT INFORMATION Account #: 990002741 Billed To: Pamela Arnn Reference Name: Proposed Facility: Residence DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SoiVSite Evaluation PROPERTY INFORMATION Tax PIN/EH #: 5748-47-1782 Subdivision Info: Location/Address: 2212 Milling Road -2702 Property Size: 5 + acres Date Evaluated: Water Supply: On -Site Well Community Evaluation By: Auger Boring Z Pit Public 'L_� Cut FACTORS 1 2 3 4 5 6 7 Landscape position IL - Slope Slo e % HORIZON I DEPTH en /1 Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure MineralogyJ_•s 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: / LONG-TERM ACCEPTANCE RATE: / REMARKS: EVALUATION BY: L 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 DCHD 05/99 (Revised) ■OE■ ■E■■ ■EM■ ■NO■ NONE NEON NEON NONE NEON ■■M■ N . . ■EN■E■ ■ENNE■ ■E■ME■ ■MEMO■ ■■■■E■ ■...■■ ■E■NO■ E...E. 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