312 Stage Coach Rd �. __ , DAVIE COUNTY ENVIRONMENTAL HEALTH ✓ (�
' ' � P.O.Box 848/210 Hospital Street �]�
Mocksville,NC 2�028 �"C��
(336)753-6780/Fax#(336)753-1680
OPERATiOPT PERMiT
�ccc►��t #: 990005850 ., '��x PIN.%.EH#: J200000021 . , . -"�:
Billcd Ta: Betty Witherspoori � � � Sufa�€ivisiort!trtf�:�-�; ' � , ' , . ,�
Re�ereE�ce N���e: . . .... _,_ ^. =Loca#ioniAddr�s�Stage Coach Road-27028 , .. .
F'ropc�sQc9 F��i€ity: Residence �.�,:,�.. ��.•. Pro��rty�-�iz�: 73 x 176 , _ .
AT*C�, �h��-• 5981 • r,�. ,,.,. �:;� . : , ..r
��TE* The issuance of this Operarion Permit shall indicate the system described on the ATC fias been installed '
in compliance with Article I 1 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. � .
System Type.: jI S.T.Manufacturer. �isQ � Tank Date� Tank Size 6Ud
. Pump Tank Size Bedrooms:_� '
System Installed By: , l9r�ller# Date:
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GPS Coordinate:
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Environmental Health Specialist Date: � �2
DCHD 11/06(Revised)
, , ,
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
: Mocksville,NC 27028 '
.. ' (336}753-6780/F�#(336)753-1680 .
- AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
�cc�►u�t #: 990005850 ' i'ax'Pl�€lEH�#: J200000021 .
�illc�To: Betty Witherspoon , Sufa�ivi�iori:trr�Z I _ _ _ _ .� .
;
R�fer�r�c� t�a�i�: ' �.. . .LocationiAd+���s. Stage Coach Road-27028 :. : ., . ,:'...,. .,:
E�rc�ptas�ci F��:i€ify: Residence � . . � , ;.; P�o��ar#yx��z�: 73 x 176 , ,�,. ;•<:= fk.<;�
��TC N�mber: �5981 � ; -, . : . , '..,.;�i : .
' Site Type: �lNew ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MIJST BE ISSUED by the Davie County Environmental
Health Section prior tp 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 y #Bathrooms c� #People �� Basement0 Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats �
� Square Footage(or Dimensions of Facility)
Lot.Size ��V" Type of Water Supply: ❑County/City f�W�ell O Community Well .
_�. ' ,
System Specifications: Design Wastewater Flow(GPD) �^�Tank Size�GAL.Pump Tank � GAL.
Trench Width�� Max.Trench Depth�� Rock Depth� Linear Ft. ��� O�
Site Modifications/Conditions%Other: a�� �,�LC�lo-�'�.
Contact the Davie County Environmental Health Section for final inspection of this system between
� 8:30=9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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� � nmental�ilealth Specialist Date:�� �1q7
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� CH 11/06�evised) . , '
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� � � � � Davie County Environmental Health
� P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
Account #: 990005850 Tax PIN/EH#: J200000021
Billed To: Betty Witherspoon Subdivision Info:
Address: 316 Stage Coach Road Location/Addre 31 Stage Coach Road-27028
City: Mocksville Property Size: 73 x 176
Reference Narrie: �
Prop�I���i�Rgmp ovement 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: '�(j.New ORepair OExpansion Permit Valid for: �15 Years ❑No Expiration �
Residential Specifications: #Bedrooms�#Bathrooms Z #People�Basement❑ Basement plumbing�
Non-Residential Specifications: Facility Type #People #Seats
� Squaze Footage(or Dimensions of Facility)
. s�arcct
' Design Flow(GPD):�� Type of Water Supply: OCounty/City �Well OCommunity Well "
Site Modifications/Perinit Conditions:
• � ' S stem T e LTAR
Initial �o .
Re air �$�
Site Plan (�'f�{1�1,� �l,
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Environmental Health Specialist + � Date ��
i.p.l l-06
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��� I TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC �
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r1J - -: Davie County Environme�tal Aealth: -
P O Bo=848/210 H ital Street
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-;(33�753-6780/Fa:(336)753 1680; :: ' � 1.,��
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1�AY`J�� caaou For: fl Siu Evaluarian/tmnrovcmcnc Pamic r Autharizadw To Conshuct(ATC) oth ��q f ��j� /q
t� Type of Application: �INew Systcm 'I IRepair to Existing System I IExpansion/Modification of Existing System 8�' �
l�mi/
*"�lAfPORTANT"•TH(S APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUfRED
INFORMATION IS PROVIDED. Refer lo the INFORMATION BiILLETIIJ for insttuctions.
APPLICANT INFORMATION
� `1 ) i •
Namc to bc$illcd �.Qi � ntact Pcrton t
Bilting Adclress Home Phone —
Ciry/StatefLiP usiness Phone .-- O �
Name on PermidATC if D�cr•ent than Above �D � 1�
� • M2iling Address ity/Sta[e/Zip
PROPERTY INFORMATION 'Date House/Facili omers Fla ed
NOTE: A survey plat or site plan mw-t accompany t6is application. Included: iu Plan �Plat(to sc:ile)
� (Pumit is valid for 60 months wid�si[e lan,no expiration wi[h comple[t plaG) _��(� � .
Owner's Name � Phone Number. !
Owner's Address City/State/Zip e
Property Address Ciry �
Lot Size PIN# �"� �
SubdivisionNamc(ifapplicablc) Sc 'on/Loi#� ,r
ir 'ons To Site: ��
�
1 die answtr u�any of u owing questions is yes",suppating docan an�st ched.
Are there any e ' ting aastewater sys[ems on die site7 Yes__I►d"� ���0���'
Does the site contain jurisdictional wedands7 =1'es a,e�y�
Are thcre swy rasemaiu or right-of-ways on the site7 �Yes L_4�1��f-o/
Is the site subjcct tn appmva!by auothcrpublic ao�cy7 ❑Ycs C_5��?i�6
Will wastcwatcr othcr thau domcstic sca^a�e be *eneratcd7 =Yes lu3vo
IF RE5IDEN E FILL OUT THE BOX BELOW �
#People #Becirooms #Ba ms Garden Tub/Whirlpool es �Na
Basement:1 Yes 1 o Basement Plumbinb� IYes o
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Foofage of Building #People
#Sinks #Commodes #Showers #Urinals
Fstimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOOD5ERVICE ONLY: #Seats �
Type system rcqucsted: I vrntion Aecep[ed 1 innovative IAltemative I IOther
Water Supply Type:0 Coimty/City Wattt ❑New Well �Existing Well C Community Well
Do you anticipate additions or expansions of the facility this system is intended[o serve?I I Ya I No
If yes,what typeT
This is to c�xtify thaz 1hc in1'orma6on providcd on this application is wc anJ wrrcc[to thc lxst of my knowlcdgc. T undcrstmd
that any permit(s)or ATC(s)issued hereaRer are subject to suspension or revocation if the site is altered,the intrnded use
changes,or if thc infottnallon submi[tcd in this applica6on is falsificJ or ehangcd i hcrcby grant right of cntry[o Ihc Au[huiizcd
Representative of the Davie County Healdi Department to conduct necessary inspections to determine compliance witli applicable
laws and rulcs. T undcrstand that i am responsiblc for thc propar idrn6fication and laliding of properry lincs and curnas and
l�g d '+g��the house/facility loca6on,proposed well location aad the location of any other amenities.
�'—B�v Site Revisit Charge
Property o er's or owner's Tegal rep entative signanue
LI D�atc(s):
� � �� CGcntNotificationDate:
Date �S=
Sign given I Yes I INo Accwnt# ���ti
Revised 11l06 Invoice# ��
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� ,: ` DAVIE COUNTY HEALTH DEPARTMENT
f � � � Environmental Health Section -
� Soil/Site Evaluation
APPLICANT INFORMATION • PROPERTY INFORMATION
Account #: 990005850 Tax PIN/EH#: J200000021
Billed To: Betty Witherspoon . Subdivision Info: Rabbit Farm Lot#
Reference Name: Location/Address: Stage Coach Road-27028
Proposed Facility: Residence Property Size: 73 x 176 Date Evaluated: —�Z
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Water Supply: Cl�ell Community Public
Evaluation By: Auger Boring X Pit Cut
FACTORS 1 2. : 3 4 5 6 7
Landsca e osition
Slo e% .
p , o0
HORIZON I DEPTH , _ cJ
Texture rou -
Consistence - _ .
Structure
Mineralo . ;, , .,.,.. ....
HORIZON II DEPTH "� -
Texture rou ' . , , y _
Consistence . `
Structure ,Nt
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: �S EVALUATION BY: �'�iW
_ ;
: n . ��
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: _,lv�.f"TY �LZfJV�S��I
REMARKS:. �
. LEGEND , ' .
Landscape Position ,
R-Ridge S-Shoulder L-Lineaz 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 ' ;
, ° �oivsrsTENc�
� , �
VFR-Very friable FR`-Friable FI-Firm VFI-Very firm EFI-Extremely firm
3'.i�t _
� 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-Angulaz blocky
SBK-Subangular blocky PL-Platy PR-Prismatic �
: j , _ _
/
�Iineraloev
`1:1,2:1,Mixed
�r rjpS� _
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-gaUday/ft2 � DCHD OS/OS(Revised)
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LEGEND
�(wE)XEREBY CERIIiY TNT 1 NI(wE Nt�7NE OwNER(5j OF THE�ROPERII' REBAR EIP p(ISfINC IRON PIN ��
DANE COUNIY PECISTER Of pEEpS �1pt.
DESCRIBm NEREOIA KHICM IS lD6VED IN TME SUBOMSION JUPoSOICfION Of pUT REGISTMTION � ��N PIN SET
MNE COUNIT AND TUT 1 NEAE MOPi MIS SBqN510N PlN!WrtN MY
(� R/W RIGFR-OI-WAY RO
iREE WnSFNf.ESGB�ISNED MMnMM NG SEiB�GN 11N6 ANU FLLED(OR REGSTRA AT ����V� O'aqc K 1� Y. EIP EDGE OF GAVEMEM ��E� L
nmrwh ut m+ecrs(nao).�wwcs.vun�s uw oTNrn srtrs uro �J Mr or.�+UC'UST' .2ois E/C Eoce ov crw2t x� ,�
FHf 70 PueuC Maw1E ' No1ED. TWS 1HE �4 � /� CM CANCREfE MONUMENT Q
� M N/D RECOPDED IN PUi BOOK �I .PAGE '7S PP PoWEH POLE `y� �
S M.BY N�NIYUY BUILDING UNE
� F0.J!!6 PA10:._���3}�Y.BRENf SHOAF.RECISTER OF OEE05 LP L1GHT PolE �
� ��� ;� F/C __E__ WLRHE�D SERVICE LINES
� ; � � �. Po�M �
Si�7E OF��Ort1H GROIiN� (n C.C. CONiROL CORNER S�E
CW!!IY OF OAVtE � .
/� � � o � QP'6
1.��N�.l�l REVI�OFTICER Oi WYIE CWNIY.CERfIFY � . . / I�
f `� nor m sw
71NT T11F MM OR PLAT TO WWCH iHiS ERI7FICATqN 6 NFIXm YEEIS ALL SfAMONY
�REWIRSA[ R(CppWXG / ���� � ; /O
i �I/�l/.�.2. DB J12 PC JO %�� �
//// ��
yp� gy� // /0 a JOSLPH TO1fELL
TA7C PIN 70�-Q- 1708 �� / � t' DB 350 PC S48
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:.ac Loxx� s�rx ",• %��C
souD S 33•58'14'V
V/ 3/�' p�174 PC 278 [RON 23.3' S 85'43'a7•E
PrvE viia[ S 86'SS'34'E 396.68' .-.� 1��• � 52.46'
2�e.as� — — — vr � �H^ ��� �CANE MILL DRI1�E
REBMS BE'S('ps•E 633.28� (;otaU -�. •
" ur S 87•1430'E 272.15�-�. —' -- � 381.92�— caqv�aarv[ PP �ir a�p �2 cnnw.
F.REEnN p svlKE N 86•46'll'V 149.37• Si�wuD
/ , fig� . � �S S B7•14'SO'E E89.9�'i� R[eat �� 37.3 � lRnl
1.�i�� 112.03• �
E N 31'31'22'E � • �i P� \\ C'�' I —_
/ �1/�Y ����� m e I 7.85' / '� EXIsitN�S�p•pR1VATE I
/ 0�CREEK N / (�Yf lAT 6/ AC iER Pi 9 PG�jiB
RAlOINERS GR�VEL DRIVE �/
P�.�� f 1.027 AC IS OVER TFE LRIE AS S/QVN /�� 0°ry
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HE"lTY 1I11�OON ' e����� e �W�� '� / I I I
P/0 DB 722 PC 29 � _ [Pi P/0 TRACi 1 y '�^ ' �
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/ . 2001-E-224 __ / ���.by �i / � I I
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/ 1 HQtEBY CERI1fY TNT,�7r.SVBpV6WN PUT SFqWN HEREON NAS BfEH iOUND TO COAIPLY / / . I I I a
WffH iNE COIRIIY SUBDM6qN RECUATqN3,WfIH 7XE IXCEP110N OF SUCH VAPoAN(Z5,If i �
ANY./S ARE NOTm M T/�YMUf6 OF T1E YIANNING BNRD ANO TNT R YW4 BEEN I
MPROVED FON RECORDIN6 N THE OFi10E OF 7HE PEG6IER OF DEEDS.R LS MQtEBY NOTFD m
/ h1AT SUCN�AL F RECOR6ITION OOES NOT N(x.UDE IPPROV�L 70 MISfN1 AND Ui4RE / ' I a
WIRIJtY F NOR .YI[LWE MPROVK i'OR T1E WNStRUC110N qt OCCUPNICY OF
BIAIDd/C5 OF 5{ff{lCIU
. 4 ,?o.t , � I �
DIFECfOR �NE MY PIANNINO D
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� ry� 2001-E-22{
~` \ �..ux�ane ea�sr nw na rv Mwsw�a`�w� � .�xaWu��°O'� ii �rRACr 3�
JESSE G. HENDRICKS
rn��,�nw.a,me.u.x„�oc„w N. R�+w a PB 9 PG 148
r�mimm w o�eoac(a.�a.a).rrcE f«�a.a).m:nw nrt u� p?tEst�c '�y�, ? w crc
K QOAlK A4 C.YCUAIFD ft UT11110E5 Ir0 D�MT� 6 1/10.000. rrPO h 4 y.
�� TNT TE Bplll}1NES NOT SUPIETID NR LqMll A9 BRq(EN(/F3 PIDRm 4 ' .
2001-E-32s n1w rwvnwnoN ipMD W ORD Boo�t(m nobe)r/G[(w mYC):nwT + 6EAl . m n � s wl
P8 9 PO 11! T�B Yw w�5 PrtE7M1ED N ICCanpwCE WrtX Cs.q-Jo AB NCqDlD. l l�9Jyn .
TMCf I ' 1MIME35 W MVID NID tW T1q�Llfl Wtt OF n�uf 2012 ��f ,�:: .� ' p�,y rq �
�r^`a'�^` °'�'. � BETTY WITHERSPOON
//�' � �/' '�•"'' sr�cccar�aaa
' TRI�COUNTY LAND G �G'"""'�V'"'�1 ��E CG DRAVING DATA DWG. No.� �TES�
, 11 1�2 �� �� $��� �� �e / SCKE�1•-50' 123247
, THOYASVIILB N.C. ZZ�36O DRAVN BY�TA
nN.nrt nn s o.awn nw acw.weaww o nntE1
� THOYASVILI,E♦ (998� 72-B40B ����a�a�r+n nwr w+ri \ �w• / �� S�VEYED BYLC.TA 06/23/2012
. I�iGTON� (398) ?d3-742C v�rc �p n�cc�o�,���o,�p CpUNTri DAVIE TAX IA 5707-58- f056
. 1fII�T3fON-9dLEY�(938) �BB-0703 / raaaviut ac 2�ose
TOVNSHIP CAWu�N STATE�NC
� GoMAPS - Davie County NC Public Access � ��
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***WARNING:THIS IS NOT A SURVEY!*** Wednesday,April 11 2012
This map is prepared for the inventory of real property found within this jurisdiction,and is compiled from recorded
deeds,plats,and other public records and data.Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map.The
County and mapping company assume no legal responsibility for the information contained on this map.