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175 Pine Forest Ln v • .. � . ,, �� � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street ,. Mocksville,NC 27028 (336)751-8760 Account #: 990003753 Tax PIN/EH#: 5718-13-3343 Billed To: Kendra Rafie Subdivision Info: ,� `7� Reference Name: Location/Address: Pine Forest Lane-27028 Proposed Facility Residence Property Size: .063 +acrers ATC Number: 4214 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLJST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any building permit(s). T'his 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 CO TRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. / Environmental Health Specialist's Signature: Date: �} CERTIFICATE OF COMPLETION � **NOTE** The issuance ofthis 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. J � �b � �/��r��� 8 � .S, / ��-�-�e ��,� ������� . ��� ----� r� �s��� �l� ���. � ���,� �y���:. �� �� / , � � Septic System Installed By: �� � Environmental Health Specialist's Signature: f���/ Date: `7�'�--OIO DCHD OS/99(Revised) � L� , , DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section r � P.O.Boz 848/210 Hospital Street �b� �c5 S , , Mocksville,NC 27028 � (33G)751-87C,0 IMPROVEMENT/OPERATION PERMIT Account #: 990003753 Tax PIN/EH#: 5718-13-3343 Billed To: Kendra Rafie Subdivision Info: � ��S Reference Name: Location/Address: Pine Forest Lane-27028 Proposed Facility Residence Property Size: .063 +acrers ATC Number: 4214 **NOTE**This ImprovemendOperation 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 INSTALLING SYSTEM. /1 Residential Specification: Building Type #People_� #Bedrooms�,� #Baths o`�`�J Dishwasher: Garbage Disposal: ❑ Washing Machin� Basement w/Plumbing: ❑ BasementlNo Plumbing: ❑ Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply��/f/ Design Wastewater Flow(GPD) ��� Site: New� Repair 0 / l� System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widttr�b Rock Depth��Linear Ft� Other: Required Site Modifications/Conditions: 11�1PROVEMENT/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 830 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33C)751-87G0.**** J�� ��`� �O t � � � 2/'O/1'/ �GQ°T`c' -S ys�� � Od. . (✓ � � �� � � Environmental Health Specialist's Signature: Date: / DCHD OS/99(Revised) � /����-��,��.�`� � a � ' �+�"',�+� . ',' ,..,, (� � � . � � '��' � A1 ' 'ClUN f OR SITC CVALUllT10N/Ihf!'JIOVEhiCNT Pi:Tihi17&ATC • e � � �� Davic County Health Department �� • Environn�enta/Health 5ection � P.O. Hox Ei4fl/210 Fiospa.Lal Straot �;�,�:����G�� Mocksville, NC 2702d � (336)751.-8760 **ItIPORTANT*** 7'I�IS APPLICATION CANNOT F3� PROCESSED V`�iJ�JJ ALL TH� RLQUIR�D INFORi•S1ITION IS PROVIDLD. Rcfer to the INrOR2SATTON BULLETIN ior inatructionu. � / � ,� ( Namo Lo be Dilled � Contact Pcraon ,1 � ��lX i � � o tdailing Addraan ��"_,.(,� ,/����� -�'QYeS'"1" �,(1 • Ifomo Plione l��ly� ���"�J Cil:y/Stato/ZIP _�\��,IC.,)���II�F') ��11J�� IIuoino�n Phono ���1�� � `JI^1.�1C�'"I � 2. Namn on Pormit•/I�TC iL Ditferont tYian Abova ��i1!��, � /� j �y/ 1� 23ailin� AddroaccJ��� �'�1�� �� � �r� City/Stato/Zip ��� I1�( l�-vY �l � ��V ���� 1 1 3. Applica�ion Tor: �iL-c �valuation ❑ Improvement PeruiiL-/ATC �oth h. syacc�n eo sc�vice: �J Jiou�re � 2dobile Home ❑ Du3ine3� I� TnduuL-ry ❑ Ot-2ier 5. Typa aynL•om roqua�L•ad:�Cl Conventional ❑ conventional modificd ❑ innovaCivo pacc;ePted c. If�.Re�idenco: tl People _�_ # I3ecIroom� � 11 DaLhroomu � L](IDi�hwa�her ❑Carbac�o Di�posal �Wa�hing 2daehino ❑Dasement/Plun�inc� ❑Danement/17o Plwnbing /� 7. If IIussincau/InduaL•ry /Othor: vcrify typc ;) Peoplc 1! Sinkn q Commodoa 11 Showoro �� Urinals If WaLor Cooloro II' FOOD�ERVICE: �R Seato �uL-ima�ed S�TaLer U�sage (galiona per day) o. 2ypo of wator aupply: ❑ CounL•y/CiEy f�4 j9ell ❑ CommuniL•y. / 9. po fou anticipato adJition� or cxp:insioc�s of ttic L•icilily tl�is system is i►itcudcd to scrvc? CJ 1'cs �No i � If�•cs,titi�hat typc? ***L1IPORT�IN1'y"**CLILNTSAIUST COdll'LCTET1fE XL•�)UIItED PROPLI27'Y lN1�UR11�IAT•►ort iiLQui.s•rcll 1 131'st.01�'. iiitl�cr a PI,AT or SI7'T•.PLAN�1fU.ST IlESU1iAfIT7'!iD by tlic clicnt with TIIIS APPLICATiON. � 1'roper(y llimci�sions: ' �Q � � 1VItITC DIItCCTIOi\S(fruni A•Iodcsvillc)(u PIiO!'Istt'1'1': r:�.orr,«rirr: ����'I 1� I ����-� � I I�� ��5� i �� I������� iU i'n � T I'roperly Address: Road Naiiic�l�X. �� �S� �,��1� ����� GI� 1��1�I� ��('�I���r}'I1,�� ctty�z;p I'�D(`,1�)�(�.�-C��. � ►��SS '�_� �-u F�a,� .�`�l 1 Y r'1 Q�_ a�, ICiu a Sul��liti�isioli providc ilitorri�a(ion,as follosa�0 �1(,�' �� ��'��ii� ��`�. `2i"�(� ��(� (`�•� rr:�,»�: �1.��i��� i-f��t���1 ��1� �C ��1 1(,n��11 u r�+, I �,�„ o s �t��,� Se v Scctiou: I3loclt: Lot: llaic ]�omc corucrs Ilaggcd: `�(l�. ��r S� L�'j� �,Di+(�t- 'I'lris is to ccr[i1'y tli:tt tlic i►ifoi•m1�lUI1 J)I•ovidcJ is coi•rcct to [Iic best of iiiy I:►io�vlcdgc. I undci•st�i�d tli;it ar�y per>>'��5��� ��`���� issucd Iicrc:iflc�'71'C SUv)CCI IO SIISf)ClIS10I1 Ol'I'CYOC�t10i1�lI�I1C S1�C j)I�I15 OI'ltlfCJl(IC(I lISC CI1:1I1�C�UI•if tlic ilifoi•luation j�� C+(�}�j subuiit�ccl iii (liis applicatio�i is f�lsificd or cliai��cd. I,also, «�ulcrs[cr��d tlrail rrur respo�rsiLlc f��l•a!!clur�blcs i�rcrrrr��d fr•v»r -- dris«pplicn�iar. I,ticrcby,biti•c conscii� ta tlic Autl�orizcd Rcpreset�t:ititi�c oC tl�c D���i ouiit}�Ilcal li cpai•tU�cut , ����������� to cntcr upun a�ovc dcscribcd pl•opcc•ty�focatcd in Davic County:t�id otirncd by �� �l (' �' `((' ( �1 G 1''C���'{-�y IO COIICIUCI :III IL`S�JIIb'Il1'OCC(Ii11•cs as ncccssac•y�to dctcrminc thc silc suit�bi it��. , (S ������,� ..n,� Di�'I'� � �� � 11� SIG1\'r1I'URL � '� ',� � f � C�- �� TIIIS AItI;A AIAI'B�US�ll rOR DItA1YING YOUR SITL PLAN(IncIudc aIl of(lic folIotivinb: L�islin�;ancl proposcJ`r�'t�L� � Z property Iii�cs anJ diinensio»s, structures, scibacics, aCl(I SC�fIC IOC:1fI0IlS�. � ('��j�'�'��!�j��) � ��jz„ d- C�,,,,,�- � �1`" Ja`'''�Q-�� Sitc 12cvisit Cl�ai•�;c � D:�tc(s): Clicrit NoliC�atioii Dalc. � �Y�✓r� +' � S JF'� I;I�IS• � � � Si�n�;ivcn Pi `�� `��.,. .Accoun[No. � �� �-Sr - -= �� Rcti�iscd llCII (US/03 � � t - �� Invoicc No. � �� �� � � � � � _�, , . . . ' . . .. .. F . � � ... .. ..*,. . . � ' . th PLAT OF SURVE.Y FOR : CertiFicote of orr�ershlp nnd dedicntlon �ENDRA 'No Approval Required by the Davie County Plnnning DepartMent' I (Ve) lwreby certlfy thut I nn C�e nre> the owner Cs) of the property RAFIE descrlbed hereon, •Nch is tocnted In the submvlslon jurisdictlon of Dnvle , Co�mty nnd thnt [ hereby ndopt tNs subdHlsion pinn ritfi ny free consent, established �w+ bu�ding setbnck lines nnd dedknte nll streets <roads>, nlleys, walks, pnrks nnd other sttes nnd ensenents to public ar prlvnte Ptnnning DireCtOr' Date CALAHAN TOWNSHIP, DAVIE COUNTY, N.C. use ns noted. AUGUST 17, 2004 SCALE: 1' = 40' 40 0 40 80 120 Date O�mer (s) GRAPHIC SCAI.F' - FEET Filed this _day of 2005. CURRENT SURVEYING & MAPPING, P.A. REVIEW ❑FFICER'S CERTIFICATE at and recorded in Plnt Bk. Pg. 1353 BRUSITY MOUNTAIN ROAD I, , Review Officer of Dnvie County, WILKES80R0, N.C. 28697 North Cnrolina certify that the r�ap or plat to which this RICHARD C. CURRENT, REG. NO. L-756 certificntion is nttached Meets atl stntutory requirer�ents for recording. Register of Deeds �r iv�enm c�oa n��s surmY aa n+E PNtT OF 1FIE SURVEYOR IS SOLELY 70 KENA2A RAFIE � • Review �fficer 1/2' �T'e �ine) C�IRRENT TAX RECORDS USED TO iDENTIFY N g2� �W " ADJOtNiNG PROPERTY OWNERS. SURVEY Pipe-�♦ 42'00 PERFORMED WITHOUT A TITLE REPORT, WHICH ,f----., 1/Z' MAY REVfAL ADDITIONAL CONVEYANCES, Date IS�00 / J Rebar RIGHTS-OF-WAY, EASEMENTS, OR OTHER � RESTRICTIONS NOT SHOWN. ' ' NI]TE + SURVEY IS ❑VER 2,000' FROM ANY PUBLISHED I N.C. H❑RIZ�NTA� GROUND CDNTROL � � N�TE � R/W IS NAMED NOTE � THIS PR�PERTY IS NOT SHOWN WITHIN THE FL��D PLAIN. � o ' PINE FC]REST LANE _ _ --� m ' ^, " , _, .-. o, � � ' �-. � � � � � ' � �� ZONED RA � � � � i � Cli�ton Cooper o m � � ~ � Bk, 91, Pg. 34 J � � a �/ ' � � V � Existing 30' R/W � L � 3' � -- See Deed Bk, 105, \��S 6�`$1, ��'J� o / Pg. 641 IS 44`E 1 a �, o' ^ . � \ \ O o0 8�S8 � l'� o � � � \ \ � �� (To�4�� � �' � z I � �� o _ \ 1 w � � �� ��' g. . 1 Z�NED RA � � � � Clif ton Cooper � 00 � I ' - -- ~ � ZON D RA . � Bk. 91, Pg, 34 � �I � � I ' � ' 3 � �� ' �, � , � � � � f���� ' � O O 0 � 63 Acre % �� �� � V � � � i I By Coordinate Cor�putation � � ZONED RA Ref, Bk, 91, Pg. 34 � I ' � Cliftor� Cooper (a portion of) � __ _ __- � \ i ` � Bk. 91, Pg, 34 . , '�' \ I � I . �s� jS� � I �� -oo, � � I . �, � 3 � � o l�� � � � � I S�, o � r], o ZQNED RA °� I c� I Clif ton Cooper Q/� — _ �� I Bk, 91, Pg. 34 •S� � . Existing 30' R/W + See D,�eed Ek, 105, � ' Pg, 641 ^ W Ip . . . .. „ pr ' I I � . ,. � o , ro ,. ,. -J � +'� � � S - � � �� . � o I^ I � _ . ' lv Z v' m . � I <_ ` n � � . SETBACK LINES � . F R ON T 4 0' ���,......«...,y \ \ 2 � . SIDE 15' •:��N s'�'s'����+ f `0 , REAR 30' •:• -Q�oFE ioti9c: y� ��\ a, �- : SEAL � \ A ' L-756 ? W O � , s: �"`'��• �_' \ � ;� t, •��iti�•.0. • ��' \ \. ���nw��� \ , VICINITY SKETCH \ \ I, Rlchnrd C. Cv�rent, Professbnnl Land Surveyor No. L-756, Certlfy thnt tNs pint Is of a survey of nnother cutegory, such as the W - NOT T❑ SCALE recoribVwtion oP extstk�g parcets, n co�w�t-ordered survey, or � � other exceptlon to the definitbn of n s . -� � See Bk. 91, P 34 for " .o � r�'� R/W fror� property ' °i ° to SR 1153 <Shad � " Rlchard C. urrent, Professlonal Lnnd Surveyor, No. L-756 � � rl y LEGEND . Knoll Lane) Z1 �* "` 1-1/4' • Iron found SF� � CERTIFICATE OF SURVEY AND ACCURACY Pipe O Calculated POIt1t ` � SITE I, Rkhnrd C. Currmt, Professbnnl Land Surveyor, certffy tho.t thls ncp rns c�^o�� ♦ Power PO�E' fron nn actuul sur ey nade under ny supervlsfon <deed descriptlon recorded I� � rJ�B' Rebar 52't ; � Bk.�_, PQ.3� , etc., Cother> that the bour�daries not surveyed nre cicwrty , ' 6� kwYcnt�d ss b-nw� Fron ir►for�►ntion found in Bk. — . Pp� thnt the rnlb _ �p � K"� �`� of preci�or► ns celculoted Is U u'_�WTthat this nnp ■os prepored In uccordunce Mlth • • �'^ � G.S. 47-30 ns n�ended Vitness ny orVpMal sler�ature, registratfon nunber nnd seui tWs .":a � �° �_.doy of A.D. 200 _ �,r,.,. . , � Cv�r C . - i; I�l Rd • Rfchnrd C. C ent, Professlonnl �n►,a s y«�, �. �-�sb Co ri ht C Current Surve �n & Ma in P.A, Au ust 17, 20D4 � JOB # D0502 ' py g � y 9 . PP 9� 9 �� � �r,' � �,. . � �,z ,: ,�ti ,.�; ` � . _ _ �'� �';�- - ..�'t. _. .. . , , .. . � . �, �; . . , �.., , , , � : . . . . , . . . . . . ,{t.. �. .. . � • .. �` � ' , � ' DAVIE COUNTY HEALTH DEPARTMENT , � � ' � Environmental Health Section Soil/Site Evaluation � APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003753 Tax PIN/EH#: 5718-13-3343 Billed To: Kendra Rafie Subdivision Info: Reference Name: Location/Address: Pine Forest Lane-�i���/ y� �� Proposed Facility: Residence Property Size: .063 +acrers Date Evaluated: / Water Supply: On-Site Well Community Public Evaluation By: Auger Boring � Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca e osition .L Slope% HORIZON I DEPTH J `' �' Texture grou L� C L Consistence � l' y�/� Structure Mineralo ,` HORIZON II DEPTH ��`� � 'c Texture ou � 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: GC � EVALUATION BY: �r�� /1 LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: t REMARKS: LEGEND I.�ndsca�e Position R-Ridge S -Shoulder L-Lineaz slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tenace FP-Flood plain H-Head slope T�Ctur.� 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 .ON�iST .N . ��415� VFR-Very friable FR-Friable FI-Firm VFT-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 , r, ,r SC -Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky � SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed 1Y0� Horizon depth-In inches Depth of fill-In inches Restrictive horizon-Thickness and inches from land surface Saprolite-S(suitable),U(unsuitable) Soil 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