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407 Zimmerman Rd � , .. r ' ' � DAVIE COUNTY ENVIRONMENTAL HEALTH ` • � P.O.Box 848/210 Hospital Street ' Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990004006 Tax PIN/EH#: 5798-26-2719 Billed To: Rick MABE Subdivision Info: Reference Name: Location/Address: 407 Zimmerman Road-27006 Proposed Facility: Guest House Property Size: 5+Acres ATC Number: 4915 **NOTE**The issuance of this Operation Pernut 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. � � �� r ��~�� i3 Tank Size rC��0 System Type: S.T.Manufacturer Tank Date Pump Tank Size�� - � � �— � �- �� ,a3^ � ^ System Installed Ey: ��so � �-et�j-P E.H. Specialist: �s�'� Date: � '��✓h.c D u..�-- c,�-o �d�� h y� �-� � �o . � �� G�^ � � P �, � �� a��- `--^ , � �� '� , c / � � ��5 � � �'j � � G a �G .�-- ✓ �G (.t. '��'n't"ti'c.i`�`'� � S r�--�`C� _ �G� 5 — �i �� \ � � , /..:�- � , , � � �� ,�,tt �. � �� `� � � � � ,� ��.��5� S �� DCHD 11/06(Revised) - � y • , . . M ' y� � . � DAVIr C0[TI�TTY ENVIRONMENTAL HEALTH ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR WASTEtiVATER SYSTENI CONSTRUCTION Account #: 990004006 � Tax PIN/EH#: 5798-26-2719 Billed To: Rick MABE Subdivision Info: Reference Name: , Location/Address: 407 Zimmerman Road-27006 Proposed Facility: Guest House Property Size: 5+Acres ATC Number: 4915 Site Type: ONew ❑Repair ❑Expansion *�NOTE**This Authorization to Constnict(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building perniit(s),(in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems,Section.1900 Sewage Treahnent and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,pl�t or the intended use change. Residential Specifications: #Bedrooms � #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size_!��5 Type of Water Supply: ❑County/City el��Community Well System Specifications: Design Wastewater Flow(GPD) o�� Tank Size �/pO�GA�.Pump Tank�'"�,, "AL. Trench Width 34!� Max.Trench Dept�G f, Rock Depth�,'-�� Linear Ft. �'7� Gd�r�id N�/ Site Modifications/Conditions/Other: �'{=� �tat�d in 151� NCw'�C 1ri}"w.1�i��i�� -e`� � �v b� �r dc��G� �Q u „�.�'::�Jti.'�.�it..r,Ts--mu, ut�,�—�i�.,�u.,:,u C�rf—tvc !_Op . Contact the Davie County Environmental I3ealth Section for final inspection of this system between 8:30-9:30a.m.on the da of installation. Tele hone# 336 751-8760. � — l - - _ � �, � � � � 3ti 1 • � �•c�S . �X��✓7 �Y�,��;n5 ld0 v�Cl�tK� ` �� \ � � � �}I�� l y6 of u��•�Y`on� � 1 � � '6-f�`'S \ � �-��Pa' ��u� i � ,� P��.a �i � \ \ � � � � __ _ � �� J /� Q �S Envuonmental�-Iealth Speciali t Date: �/ % OU � ..nttr� , �in� m__�.:_...1\ �O� I/ . O� , • ' Davie County Environmental Health � • ' P.O.Box 848/210 Hospital Street ' , ' Mocksville,NC 27028 • (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT ' Account #: 990004006 Tax PIN/EH #: 5798-26-2719 Billed To: Rick MABE Subdivision Info: Address: 407 Zimmerman Road Location/Address: 407 Zimmerman Road-27006 City: Advance Property Size: 5 +Acres Reference Name: Proposed Facility: Guest House **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: ew ❑Repair ❑Expansion Pernut Valid for: 5 Years ❑No Expiration Residential Specifications: #Bedrooms �� #Bathrooms #People Basement� Basement plumbing0 Non-Residential Specifications: Facility Type #People #Seats Square Footage(or D'unensions of Facility) Desig�Flow(GPD): a t d Type of Water Supply: ❑County/City �11 ❑Community Well �S StetCd I'�l 151a �JCAC Z-.r>iy.1.�,^5;��'j� Site Modifications/Pemut Conditions: �c�ent��d CvstF��in� .,,,_, <;,r.�, k,.., .,`�, S stem T e LTAR Initial c ,� Re air Q c e '�Q `�` h Site Plan � �" ` — —� — /� �-' i (ha~�� _ � �_ �� .�e �-4''� / � � � '— — � \ � `� �. _ � ` ,� , ( /~- _ �. ��'> > 5�Y �� ' y � � �' �' oo�oF �k��" � �� '�°' � ' :�4: l 5.� T��- ��o' 1 / t � � � \ ��.�,pa,y ' / \ ` Y ►'ti�' / ,,>°� � � ` , —;L.. — �c s�./ --�_ —. � � — � �� `p ��' d�� / ��' � � Environmental Health Specialist �%!� Date�/ ^�� i.p.l 1-06 Oct 14 08 03:35p Davie County Environmenta 3367518786 p.1 .. ;� � � . " • ' �i�, �P� \FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC � , `C, Q Davie County Environmental Health w '�`,� 4�':�'" P.O.Box&38/210 Hospital Street `� r � Atocksville,NC 27028 � �� t `t.' ., �1 � �t ��, '' (336)751-87G0/Fax(33�751-8786 ` ' 1 ,�'` 1 �,,�,. ,e�'-�,� QCApplication For.. ,S't�Evaluari provement Permit 0 Authorization To Constn:ct(ATC) �Both YP �YPP��t '� -.y.\ ,, T e ofe i" ��: Ne �stem ❑Repair to Existing System ❑Expansionllvlodificadon of Existing System or Facility .h't�k�.,� e�t'p.\.`:.` .1;�� ,'\ ��. "``'`s*j�i�61� � *"TEIIS APPLICATTON C i1V.�VOT BE PROCESSED UNLESS ALL OF THE REQUIItED . �INFO TION IS PROVIDED. Re(er to the Lv'FORMATION BiTI.LETIN for inshvctions. APPLICANT INFORMATION !j Name tobe Billed � Contact Person�,C� �Q�JQ. Billing Address 0 Home Phone qO1�—G,�`� (p , City/Stater'ZIP � Business Phone Z�S^3 L{, � ' Name on Permit/ATC if Different than Above Mailing Addtess CityiState!Zip PROPERTY INFORMATION *Date House/FaciIi Comers Flagged * / rQ�� i NOTE: A survey plat or site plan must accompany this applica6oa Included:0 Site Plan ❑PIat(m scale) � �/�G �� I (Petrnit is lid for 60 m nths wi ite plan,no expiration ith complete plat.) (] r /n �11(t � Owner's Name P hon �1ym ber "(�l 6 'b a 7 Owner's Address� _CityiS te/ ip �d1�f, /UC� ' Property Ad ss City V R � Lot Size Tax PIN�f � �27/�' � Subdivision N'ame(if pplica ]e) Section/Lo# Directions To Site: e re (` O ' /� �� nn r►s n tr.o.� S') } N If the answer to any of the follo�ving questions is`�es",supporling dociun tation musc be attached. Are there any existing wastewater systems on the site? �'es ONo I Does the site contain jurisdic6ona]wedands? OYes�1Vo ` Are there any easements or righFof-�vavs on th�sitt? 0 Yes p2� ; Is thz site subject to approval by anothez public agency? �Yes� Will waste�vater other than domesric sewage be generated'? ❑Yes o IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub!'l�'hirlpool es CNo $asement: es ONo Basement Plurnbing: es CNo IF NON-RESTDENCE FILL OUT THE BOX BELOW ' Fype of FacilityBusiness Total Square Footage of Building #People #Sinks #Commodes �Showers �i Urinals Estimated Water Usage(gallons per day) (AttacF.docuarentation of similar faciliry water consumption) � FOODSERVICE ONLY: #Seats � Type systemrequested: �oneentiona] CAccepted CInnovative ❑Altemative �Other R�'ater Supply Type:0 CountylCity Vb'ater �te�v Well ❑Existing Well ❑Community Wzll Do}rou anticipatz addirions or expansions of the facility this s}5tem is intcnded to serve?❑Yes �No If ye;,what type? This is to certify that the informztion provided on this application is Cve and correct ro the best ofmy Imowledge. I undershand tl�at any perrnil(s)or ATC(s)issued hereafrer are subject to suspension or revocatlon 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 Aathorized Repre�entarive of the Davie County Health Departrnent to conduct necessary inspecrions to determine compliance aith applicable laws and rules. I understand that I am responsible for e proper identification and labeling of property lir,es and comers and locating and flagging king the h /fac'ity locaci n,p. osed well IocaUon and tfie location of any other ameni[ies. Site Revisit Charge Prop �ty o ers or owner's legal rep esentative sigttature ` Date(s): Client Notification Date: Date EEIS: Si�ngiven ❑YesO�o ' Accnunt#� ��v Revised 7 1;06 Lnvoice# • , PAGE OF • _} PROJECT BY ��.; y av, � � � PRODUCT DATE OI�C�S�I� CUENT CHECKED Precast� DATE ue\\ �� No�e �i�k SC��-,C C�.. ;�� .¢� -� � � � �� ` a ' � 1�ovse ti� � a��3•a e�� I�� C��mb s�� —�— �aNk � S�e� � �.�.:�5 C�eel� ��N � � �C/ . O� www.oldcastleprecast.com OLD 315-R5/05 , � ' � • � DAVIE COUNTY HEALTH DEPARTMENT . � � � ' Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004006 Tax PIN/EH#: 5798-26-2719 Billed To: Rick MABE Subdivision Info: Reference Name: Location/Address: 407 Zimmerman Road-27006 Proposed Facility: Guest House Property Size: 5 +Acres 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 � Slope% HORIZON I DEPTH —� U�' Texture grou L S'L Consistence S tructure t� 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 RESTRICT'IVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATION BY: � _ /' LONG-TERM ACCEPTANCE RATE: ' � .'� OTHER(S)PRESENT: / REMARKS: LEGEND T,�ndscape 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 T�1iL� 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 ('ONSISTENCE D�i�� VFR-Very friable FR-Friable FI-Firm VFI-Very finn 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 Str�ctLre SC-Single grain M-Massive CR-Crumb GR-Granulaz ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogv 1:1,2:1,Mixed , LY� �/ Horizon depth-In inches Depth of fill-In inches F 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 witl:ct� a 2 or lPss Classification-S(suitable),PS(provisionally suitable),U(unsuitable) LTAR-Long-term acceptance rate-gal/day/ft2 � ^ ' - � . • , �� ,• ' Davie County Environmental Health ' • � ' P.O.Box 848/210 Hospital Street Mocksville,NC 27028 • (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990004006 Tax PIN/EH #: 5798-26-2719 Billed To: Rick MABE Subdivision Info: Address: 407 Zimmerman Road Location/Address: 407 Zimmerman Road-27006 City: Advance Property Size: 5 +Acres Reference Name: Proposed Facility: Guest House **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: ❑New ❑Repair ❑Expansion Pemut Valid for: ❑5 Years ❑No Expiration Residential Specifications: #Bedrooms #Bathrooms #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Desig�Flow(GPD): Type of Water Supply: ❑County/City ❑Well ❑Community Well Site Modifications/Pernut.Conditions: S stem T e LTAR Initial Re air Site Plan Environmental Health Specialist Date i.p.l 1-06 . DAVIE COUNTY ENVIRONMENTAL HEALTH , • ` � � . ' P.O.Box 848/210 Hospital Street ' • . �. • Mocksville,NC 27028 ' (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 990004006 Tax PIN/EH #: 5798-26-2719 Billed To: Rick MABE Subdivision Info: Reference Name: Location/Address: 407 Zimmerman Road-27006 Proposed Facility: Guest House Property Size: 5+Acres ATC�,��,��Theissuance 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. System Type: S.T.Manufacturer Tank Date Tank Size Pump Tank Size System Installed By: E.H.Specialist: Date: DCHD 11/06(Revised) . DAVIE C0[TI�TTY ENVIRONMENTAL HEALTH ' P.O.Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax#(336)751-8786 AUTHORIZATION FOR bVASTEWATER SYSTEVI CONSTRUCTION Account #: 990004006 Tax PIN/EH #: 5798-26-2719 Billed To: Rick MABE Subdivision Info: Reference Name: . Location/Address: 407 Zimmerman Road-27006 Proposed Facility: Guest House Property Size: 5 +Acres ATC Number. 4915 Site Type: ❑New ❑Repair �Expansion *#NOTE**This Authorization to Constnict(ATC)MTJST BE ISSUED by the Davie County Envirorunental 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,p11t or the intended use change. Residential Specifications: #Bedrooms #Bathrooms #People Basement� Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Faciliry) LotSize Type of Water Supply: OCounty/City ❑Well ❑Community Well System Specifications: Design Wastewater Flow(GPD) Tank Size GAL.Pump Tank GAL. Trench Width Max.Trench Depth Rock Depth Linear Ft. Sile Modifications/Conditions/Other: 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. Envuonmental Health Specialist Date: � ...,rrr� , i�ni /n__.:,..._t� � . �o Filed for registration at o'clock M. This the Day of 20 Q� and recorded in Plot Book Page N 1 Register of Deeds I (we) hereby certify that I am (we are) the owner(s) of the property described hereon, which is located in the subdivision jurisdiction of Filing Fee Paid. Davie County and that I hereby adopt this subdivision plan with my free SITE consent, established minimun building setback lines and dedicate all By streets, alleys, parks, and other sites and easements to public or Assistant/Deputy private use es noted. County, North Carolina signed v Date LOCATION MAP m N Davie Review Officer Date signed / State of North Carolina County of Davie oI, Review Officer of Davie County, E certify that this map or plat to which this certification is affixed meets all statutory requirements for recording. Review Officer S Date � 1 NO APPROVAL REQUIRED BY THE ,.0,o<9rONE FOUND JIMMY DALE SWAIM SHELLEY JO SWAIM DAVIE COUNTY PLANNING DEPARTMENT. D.B. 474 PG. 776 Signature % MOYER F. SNOW JR. PLANNING & ZONING DIRECTOR > MARY W. SNOW �0 0.8. 2Q3 PG. 501 _ PRELIMINARY P L" . FORREVIEWONLY surveyor Certification for Subdivision I, John Richard Howard Professional Land Surveyor, Number L-2890 Eip NIP ` certify to one or more of the following as indicated by an X: CONTROL CORNER x a. That the plat is of o survey that creates a subdivision of land within the area of a county or municipality that has an ordinance that S 78-53,18.E NEW EASEMENT JIMMY D. SWAIM o^ regulates parcels of land; PIP-1 493 56' ,� ` D.B. 200 PG. 201 b. That this plat is of a survey that is located in such portion of a p county or municipality that is unregulated as to an ordinance that regulates parcels of land; d. That thas is a survey of an existing parcel or parcels of land; NX c. That this is a survey of another category, such as the recombination of ,SOT Dem 1 N 1 existing parcels, a court—ordered survey or other exception to the H 2� 101 t definition of a subdivision; �0'�i e. That the information available to this surveyor is such that 1 an unable Spm `o to make o determination to the best of my professional ability as �, HOUSE to provisions contained in a. through d. above. 2 �\\ ` � , 30' EASEMENT CORNER O.B. 184 PG. 718 Signature L-2890 p D.B. 164 PG. 546 — -- — -� _ Y 3.7843 ACRES a'- S �c�� O.B. 164 PG. 549 _ _ — _ _.- — —— — — — surveyor IMP _ _ Davie County, North Carolina 9 'b �m 81,84, OS�7.2 r — —" — --► — ._..— N 8536'35"E�5,9,7.37 — I BOBBY GRANT MINOR 60�$+j5 �,a $. f�a� N N 12S,g� pp �.4. (_TIE LINE ) MICKY ANN MINOR C� y62' ��+� rdti� �L D.B. 76 PG. 402 Z ��'�; N `�'NtP ` D NIENLEE ADAMS01 .5 0 \ D.B. 175 PG. 596 / GARAGE �� h 11 0 _. ..I Nle HOUSE 1.248 ACRES �N� DONNIE LEE ADAMS Z VICKIE N. ADAMS -► Z UONSTRUCTION NIP NDER C-) 1`J D.B.�'� 205 PG. 900 �-'� / / HE ti / PRELIMINARY PLAT ONLY w•No lc) o? _ / / FOR REVIEW ONLY � cp 9n� � t.4114 ACRE / N 88'01'13"W �' � / ' „w / I John Richard Howard certify that this plat was drawn under my supervision 95'7 IP ��O / EIP 61�3000 0 SHED NIP from an actual survey made under my supervision (description recorded in 63.25' 32.49' G�S f—� APPROXIMATE FLOOD UNE Deed Book ,Page or Plot Book ,Page ,if applicable); _oy OND COMMUNITY PANEL NUMBER 3710578800K that the boundaries not surveyed are clearley indicated as drawn from Z�� C _� information found as indicated; that the ratio of precision as calculated •p % -- —"—' — — is 1; 20.000 ; that this plat was prepared in accordance with G.S. 47-30 NOTE. � , ` as amended. Witness my original signature, Registration number and seal O u'O / This the 14 Day of MAY 2009 IRON IN CREEK IS 7.85' OFF LINE. PROPERTY LINE IS IN DISPUTE WITH BOBBY GRANT MINOR. MINOR'S DEED CALLS FOR THE UNE j' '� Professional Land Surveyor NO. L 2890 TO RUN WITH LOUIE ZIMMERMAN LINE. Davie County, North Carolina LOUIE C. ZIMMERMAN'S DEED, D.B. 56 PG. 284, LINDA GENE PITTS Ob CALLS FOR UNE TO RUN FORM STONE TO STONE. J �$ D.B. 743 PG. 700 THIS IRON CREATES AN OVERLAP WITH `L�' \ P.8 9 PG. 284 TRACT 2 LINDA DENE PITTS DEED, D.B. 440 PG. 751. �� \ LEGEND Q 1" STONE �ND Q� \ — POWER LINE 100 0 100 200 300 �S NE 11119 "D NOTE: — — — _—— — — EA u GRAPHIC SCALE — FEET LINDA DENE PITTS \ CREEK/POND D.B. 440 PG. 751 12ONING: RA — —••—••— FLOOD LINED ly (J 2. NCGS GRID MONUMENTS LOCATED WITHIN 2000'. '/2 Mf NEW I r l�1 11 RON PIPE MOR RICHARD K . & PENNY M. MABE 3.SISITE IS LOCATED WITHIN WS—IV WATERSHED. f 4.TOTAL AREA 6.4437 ACRES. NIP 5.TOTAL TRACTS 2. EIP °GSnic IRON ' 1AAR 1 9 2010 ® STONE SCALE ri TOWNSHIP COUNTY STATE DATE'S REVISED PP POWER POLE 1" = 100' 1 FULTON DAVIE N.C. 5-14-09 ENVIRONMENTAL HEALTH RECOMBINATION OF D.B. 164 PG. 549 AND D.B. 205 PG. 901 2-23-10 THE PURPOSE OF THIS REVISION IS TO DAVIE COUNTY DIVIDE LOT 2 INTO LOTS 2 AND 3. REVISION OF P.B. 10 PG. 87 CREATING LOT 3 HOWARD SURVEYING JOB NO. JOHN RICHARD HOWARD PLS 09010 P.O. BOX 276 ADVANCE, N,C, (336) 998-5396 ��' ��.► Davie County Environmental Health P.O.Box 848/210 Hospital Street ' :' ` ' Mocksville,NC 27028 '"�� , (336)753-6780/Fax(336)753-1680 W�LL PERMIT � �� Acct�u�t #: 990004006 "��x P1Ni�H#: 5798-26-2719-Well Biflt;� Tc.�: Rick MABE St�E�di�fiSlOfl If1�U: Refer�r�ce N��i�: LocationiAdi�r��s: 407 Zimmerman Road-27006 f�ropc�s�� F��:iiity: �,��e�l.hd�� 'cp��riy S�i��;: New Survey "� a`�TC Nu�b�3-: 0051 Actions of the employees of the Davie County EH Section shall in no way be taken as a guarantee that this well will produce water of any particular quantity ar quality ar for any amount of time. This permit is valid for a period of 5 years from the date of issuance. This permit may be revoked if it is determined that there has been a material change in any fact/circumstances upon which this permit was issued. Permit Type: New � Repair ❑ Abandonment ❑ Proposed Well Location Diagram : ' Certificate of Completion Diagram . � . ;I � 1 . ; �1J`� V� �`[ + � �u1�'v � � r�(�. Comments: cS � Driller: �(`��P� �j�(�`jlA`)Y�, � � � b ` Certification#.�� Grout Inspected:_�_��_Ta.�� Well Head Inspected: GPS Coordinates: EHS: Date: � EHS: Date: w.r.�-os � , , ,� .. • ,�,.�-�.�' ,� ,\ (! . 1� � � � � 1 .� . 4 � / � �PF I TION FOR PRIVATE W�LL PERMIT a• �'` � � : 0 20"' vie County Environmental Health y` { �' ` P.O.Box 848/210 Hospital St leet U�ME��P�HFAL�N Mocksville,NC 27028 "Dp��ECOU�� (336)753=6780/Fax(336)753-1680 �!� ***IMPORTANT`�** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. � APPLICANT INFORMATION Name to be Billed�i L'I� ��/al,a� Contact Persox Billing Address D ' Home Phone - 2'1 City/State/ZIP 1l /1�� EI/C ?�'��(��v Business Phone 3 tlS-��75" Name on Permit if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION .*Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) Owner's Name �i�(C. /�;}� Phone Number Owner's Address ��1✓11� City/State/Zip Property Address City Lot Size ��'L %�C< Tax PIN# Subdivision Name(if applicable) Section/Lot# 1�irections To Site: � "' O� U �1 � � � . O 2 6 � / %C' f' O �IrN�e./- /3N �1�� DEVELOPMENT INFORM TION Permit Type: New Well Well Repair Well Abandonment Other(specify) Facility Type: Residential Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES NO Do You Intend To Install A New Septic System On This Site? YES NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible. "'� By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to ;-determine the best location for a we1L � �C g �Signed Date Site Revisit Charge Date(s): Client Notification Date: EHS: 7/30/09 Account# d Invoice# • •-; �� . � � j� .�� „ , llE�iSIDENT.IAL WELY.CONSTRYTCTION�CORD ' -( � � I�orth C,arolioa�epartmcat of Emirmueent and Nataral Ytesowcr5-Division of Watcr Quatity �•�o;,.o" 'I�V�i,I.COi�1']7ACTOR CERTIFiCA'�'ION# 2312 1.w�lL CON7ie�CTOR: g. WATER ZUNES(depth): hris J�B 1)ins _ Tov 118 eonom�l2o Yop eocmm WeU Contrdclor(Individual)Name ' 7op 275 eottom 276 Top Bottom Ravmon rown ell Co. : Tov eo�m rop eoa�m W�II Contractor COmpany Name TAkkne9al . P.O. Box 337 ; T. CA81NG: o.pu, Dtametcr wo�gac �eAr��i StreetAtl4re6s : Top 9otlom 67 Ft 6 1/4 Sdf 21 qvC Dat,burv _ NC 27016 Top sotmm Ft. Ciqr or Town Slate Z�p Cade 33 593-8 39 T°� gottom__Fc Area code Phane number e. GROUT: peptl� Material MelhoO 2.WELL INFORMATION: � Top 0 6ottam 30 FL D0�1' WELL CONSTRUCTION PERMI'T'� � Top Bot6om Ft,, _ dTF1ER ASSOCIATED PERMfTs(d apqicaDk) : Top BoYom Ft._ _ $ItEWELLIDl�reppUwbie) : �, gC�EN: Dopth Dtameter Slot3ize Mamrlal S.WELL US�(CheckAppf�ble Box): Resiaentlal WsmrSupply❑ ' Top eottom Kt. in. in, DATE DRILLED O -Z4-�O : Top Bonom Ft in. in. ,,_/ � Top Bottom Ft. In. In. TIM�COMP�ET�D a:QO �„ AM❑ PM L�I 4.WELL LOCATION: : 10.SANOfGRAVf1.PACK: cmr: courrrr Davie �� s� �� Tpp Bogom Ft. _ 407 Zimmerman oad Too aom� Fc (Shee1 Neme,Numhers,Commutiry,SuESvision,tnt Na,Paral.ZiP(',ode) TOp BDltorfl Ft - - — TOPOGRAPHIC/LANO SH7'T'ING: �d+eaceppropAate moq ��,ORILLING LOG pslope pValley OFiat oWdge pOth�r Top 8ottom FormationDescrtptlon 1A7lTUDE � ._�' "DMS OR 3x.xxxbt)ootX Ob � / LONGrrUDE 75 "DMS OR 7x.xx�OocXxxx DD : 0 /6 cley LahtudeAon�ih,de souroe: �P5 Clropopraphic map � (Ioc2Non of�n musf be shown on s USGS topo map aadatisthed fo 6 /60 Sand rOCk fhls fonn'rf r►at usJng GPS) � e.WELL OwNER 60 /905 grantte / Rick Ma�p. _ � Uwrtet Name r / Streat Address / — Ll� / Cily or To�rn Smta Zip Code / 3c 36 _� � Area code Prtone num0er � 12. REMARKS: 8.VYELI OETAIIS: a. TOTAL CEPTH�305 b. DOES IM�LL REPLACE EXISTING YY�LL� YE3❑ NO� � 1 DO HEREBY CHRTIFY THAT TH1S WELL WAS CON51"RUCTED IN c. Ww�R I.EVE�Below Tov of Caslnp: 30 FT. : ��Ra�CE W�15A NCAC 2C.WE�I CONSTRUC710N (Use'+"If Ahove Top of CasinO) : 3TANDARDS,AND 7HAT A COPY OF l'HIS REC�Rb MAS gEEN : PROVIQED TO THE WELL OWNER. d. TOP OF CASiaG IS � FT.Above Land Sv�' rrop of casing terminated aVor bebw land suAace maY require 03-25-10 a va►ianoe In soourdar�ce with 15A fJCAC 2C.0118_ SIGNATURE OF CERTIFIED 1M1/ELL CONTAACTOR DATE � o. YIE�D(gprrq: 20 METHOD OF 7E8T�(]Flt � Chri&J.Buliltt6 f. DISINFECTION:Type,dTH Amount,�OZ : PRINTEP NAME OF P�RSON CQN3TRUCYING THE WELL Submit within 30 days of comptatlon L�:Diviaion af Wate�Quallty. Informatlon Pru�esatng. Form GWta 1617 Mai1 servlce Con�er.Rsleigh,NC 27699•161.Phone:(91�)807-a300 Rev.2/09 . . . -�� h �. u�1�� ;,� . Q�,,�r ��'A' ► Gva�Gl4� � .- 'APPLICATION FOR SITE EVALUATION/llVIl'ROVEMENT PE�T &� ATC p Davie Coun Environmental Health � �� c�rvED �'YIC �PlA��'� . P.O.Box 848/210 Hospital Street �// . ��; �"t , • li'Iocksville,NC 27028 DYu; T !��`� �, , � (33�753-6780/Fax(33�753-1680 Application For: ❑ Site Evaluation/Improvement Permit I�Authorization 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 TI�REQUlRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION ' Name J/�SO/� (fl ' Contact Person Address � q 2��✓�N�Crri�t� Home Phone 33G-`14 b' .�7 City/State/ZIl' v an CG NG � Business Phone �36—�62—-7 y3� � Email �tiSa►�'''��heUl ,ya o�.�� Name on PermitlATC if D�eNent than Above Mailing Address ' City/State/Zip ' PROPERTY INFORMATION 'kDate House/Faciliiy Corners Flag ed NOTE: A survey plat or site plan must accompany this application. Included: 0 Site Plan ❑Plat(to scale) . (Permit is vali�i for 60 months with site plan,no expiration with complete plat.) Owner's Name ��^ �al�,' Phone Number Owner's Address 389 Z�M�"'tP�M� RG� City/State/Zip Gtc(�i�� : N�. �7019 Properiy Address 3�� Z`;r✓�M�rrnn� 72c( City (,��(lian� Z Lot Size I •� aC r c S Tax PIN# � Subdivision Name(if applicable) � Section/Lot# Directions To Site: Specify Problem Occurring: � � IF RESIDENCE FILL OUT THE BOX BELOW � #People #Bedrooms � Bathrooms � Ga.rden Tub/Whirlpool ❑Yes ❑No Basement: es ❑No Basement Plumbing: es ❑No IF NON-RESIDENCE FILL OUT TI-�BOX BELOW Type of FacilityBusiness Total Square Footage of Building #People #Sinlcs #Commodes # Showers #Urinals Estimated Water Usage(gallons per day) (Attach doctunentation of si.milar facility water consumption) FOODSERVICE ONLY: #Seats Type systemrequested: �onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: ❑ County/City Water ❑New Well C4�xisting 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 lrnowledge. I understand that any permit(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 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 unders�and that I am responsible for the proper identification and labeling of properry lines and corners and locating and flagging � r stalcing the house/facili location,proposed well location and the location of any other amenities. roperiy owner's or owner's legal representative signature Site Revisit Charge N//�//� ' Date(s): ' Client Notification Date: � Date EHS: • � ��9�� G'��.�i� Sign:given ❑Yes �No Account# Revised 11/06 Invoice# � • j �� " � _...._......' -. .��,.. �r'� �i f,/ .r .. . � _.....,�-. ..� �,,,r ` ,_,..,..__.� ,. . 3 �`' ' ... ^ ....... ....... ��'i�Ylj".1�1 •" r�rv�R�y f].l ..... ..., � '� . ... � (T . ..:.... . _� rj ,f . �.........................�.�....�..�.+-.....�� ...__—._.-- . ��. .�f ` ` i : i� � � ��, ��r ,........ � 38a ,,.p,,� ' xa�'a _ �._ . __....._.� ��..•.,---.�"'.� , ,. �.�....._ ..��. ,,. ... � , ; � 3 __.. ,' ." __.__"� �—_--•---•— .. � � ..; F. ,, _ ........ �i � �� . . a. ♦ � p, ` '.... .. �� .. ...........-. .:s�' � . .::�..�,..;. 1�� ``�� Y �P�rF A�I data is provided as is without wamMy or guarontee of any kind etther expressed or implied including but not�imited to the Implied �� wartanties of inerchantability or fdness for a particular use.All users of Davie County's GIS website shaii hold hartnless the County of �t/ti� � �� Davie,NoRh Caro�ina,its agents,eonsuttants,contraetors or employees from any and aU c�aima or causes of action due to or aAsing out Pri nted:Apr 15, 2015 � of the use or inabiliry to use the GIS data provided by this websfte. . . i -� 1 ' `�^� ' � � � � � �,� 1 P �a " �� °� d o��,� ,�, o� �o � � � Q�1 rn"rJ_ r � , `-� .� �J �� j �_s I � � �J.� `�, ��-�-------` ,� � n„ � � �7�1. Ja � � y� V � ) ,� � $ c ,�� , . � C �� . � �� , :�'� � , �� ,�� . �� . � � �'� . -�� „ . . . + DAVIE COUNTY ENVIRONMENTAL HEALTH � ,. P.O.Box 848/210 Hospital Street ' Mocksville,NC 27028 � (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION �cct�u�t #: 990004006 'f�x F�IC�€.�EH#: 5798-26-2719-�bN� BiElc,c� Ta: Rick MABE SiJ�C�1511:�i0fl ITI�t?; Re�er�r�ce Rla�i�: Lac�tionrAdi��ss: 407 Zimmerman Road-27006 Propc��gc9 F��:ility: :� , �;,�,^;. P�a�er�y�ize: New Survey Site Type: C�ew �Repair ❑Expansion a�TC N�a�b�3': 5050 � **NOTE**This Authorization to Construct(ATC)MiJST 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 #People Basement❑ Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size��_ Type of Water Supply: ❑County/City ❑Well 0 Community Well � System Specifications: Design Wastewater Flow(GPD) Tank Size "t`XN� GAL.Pump Tank�GAL. Trench Width 3�O Max.Trench Depth Rock Deptht"/ir Linear Ft.�� Site Modifications/Conditions/Other: a�lo %Q�U��'�S(/S� . 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. -�S'f � � � '�`n" � �2�, � � y�rl� o f orcC� "`� . �, �a, ✓' f� t� �ra�..n�''c�of. , �`�'�� . �� . �'� . / a' ,�J�, . � � c�z�� ,�, 1 � � . � o�� 2��, , ?') Environmental Health Specialist Date:_�� DCHD 11/06(Revised) .. - �- • � ' DAVIE COUNTY ENVIRONMENTAL HEALTH , � �._� P.O.Box 848/210 Hospital Street • Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Acc��t �: 990004006 '��x �I�€i�H#: 5798-26-2719-� Bi(Ic� To: Rick MABE Su��di�risiort Ir�ft�: Refer�E�ce Rl�n�e:: Loc�iioni4d�E��ss: 407 Zimmerman Road-27006 f�ropc��Qc9 F��:iEity: : , �:,� ;'�; P�o��rty Siz�:: New Survey Site Type: C�3'�Tew ❑Repair ❑Expansion a�TC N�mber: 5050 **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 Specitications: #Bedrooms�#Bathrooms #People Basement0 Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Lot Size�_ Type of Water Supply: ❑County/City ❑Well ❑Community Well � System Specifications: Design Wastewater Flow(GPD)�Tank Size�GAL.Pump Tank,�� GAL. Trench Width 3�O Max.Trench Depth Rock Depth (/�1� Linear Ft.�� Site Modifications/Conditions/Other: a�lo %��(F' � !� �'�,�5� 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. -�S'� � � � '�"'t- �Z . , � �� ,f onc� �"`P � � � � p �� w drok.n �''c�of. , ��-� . C� 3'� / Z� ,�JL � M C�z�� ,� 1 ��—, �, ____— � o�� , ?) Environmental Health Specialist Date: � � DCHD 11/06(Revised) . . - . . ' - c� �� SC�.l C� ��l S �/�C� � • . � � • � DAVIE COUNTY ENVIRONMENTAL HEALTEI �� ,��'Q�� ,�LJ" ' P.O.Box 848/210 Hospital Str��t — � Mocksville,NC 27028 ��I , ' (336)753-6780/Fax# (336)753-1680 , , OPERATION PERMIT �� ccr_►u�t #: 990004006 �"�x�I�f.%EH#: 5798-26-2719-I�frFF 8iEle�7c.�: Rick MABE �ubt�i�i�ior� ln�c�: R��er�E�ce Nan�e: LocaiioniAdi�r�ss: 407 Zimmerman Road-27006 f�rc�pc��Qd F;�ciEity: `' � �+�- , . +ei� Pro��r�y S�ix.�:: New Survey �' f�TC �Iurnb�r: 5050 � **NOTE** The issuance ofthis 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. System Type: S.T.Manufacturer Tank Date Tank Size Pump Tank Size System Installed By: E.H. Specialist: Date: DCHD 11/06(Revised) . J � ,� . Davie County Environmental Health ' P.O.Box 848/210 Aospital Stre�t — , Mocksville,NC 27028 ' (336)753-6780/Fax(336)753-1680 IMPROVEMENT PERMIT . �� Account #: 990004006 Tax PIN/EH#: 5798-26-2719-1A�eM Billed To: Rick MABE Subdivision Info: Address: 407 Zimmerman Road Location/Address: 407 Zimmerman Road-27006 City: Advance Property Size: New Survey " Reference Name: Proposed Facility: ` . � **NOTE**This Improvement Permit DOES NOT authorize the constructioti 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: �New ❑Repair ❑Expansion Permit Valid for: �5 Years ❑No Expiration Residential Specifications: #Bedrooms�#Bathrooms #People Basement� Basement plumbing❑ Non-Residential Specifications: Facility Type #People #Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):� Type of Water Supply: ❑County/City tP�Well ❑Community Well � Site Modifications/Permit Conditions: S stem T e LTAR Initial °tl ' Q Re air a • ? Site Plan � ko p .._.-- 'y�``�`°�' 1� s �'�' ` �. Environmental Health Specialist ' Date�� i.p.11-06 C� -, �� .. / I h � �r` � � �� J� � � G� � �a' (� `��''�" .�.�. . , --- �� I u �� q � � �� / /,� ` 1 , G' f`-C \ 4 rrl.�� 3�"�` ` �"'.-.�_---�� W V'1 1 /" r�t S, I 1 G G .� �U�`�G� �, � � ` � � o � �,°� � 2.0 , �, e�,P �� ' � �� , �� 5 �-� � J � i _.. _._-..._ ._ . .. ,..._...._.-�.__,, .,......_..,, ' ' ;t2'7 . STATE OF NO&TH CA&OL[NA—D�vie Conat�. Tfi13 DEED,I�de Hils the�...3.8�....._._.__dsy oL..___._._._._ Ndvembex' _..........—._�,1971,b� Pantha A. Hroxn (xidoM of D. H. Broxnl^___�__�Y_,,.,�_ �__. ...................__......�__Y.. ..�_. ._._ .__.__.._ oL........Daris...._.�..County,State ot North Carollm.Pul1!....._..ot the Snt part,W..._�.....,.—_._.. Ds,�4..H.r...H7Co�.�d.!'r�fe..,._.Glenda B. Brown_._..__.._......_.._..._.._.._....—ot___..._.._Ds,Ya,4._r......—County State of NortL Cuollna,part i80„of the aeeond p�rt;Wllneroeth That tha wW partZ.__u ot the 8n!p�rt 1n wnsldewUon ot I �:10_00_ov_c___.� Ten Dol2ara and Other Valuable_Conaiderationa ___,__, _._to ...her......._.._...patd by ehe e.id part_ie a_oi sha second pert�the receipt ot which Is hereby aclmowledged,hae/9@�3 bargalned 1 and sold,md by these presenta do e8._...bugaln,sell�nd convey unto the sald put.�+.R.�..ot the eceond put an3..Ci�1.11�.T.••... hein a tnct or parcel ot land Sn the County o1 Davle and State ol Notth Carollna, 1a____.�Ck�Yille_______„__�,__ - TownahiP�adjolning the lands oL..�...___�._........_......___.__..................__....».........____..-._..._._._.._.._......_.---....._.�..._...... rnd others,and bouaded u follows: • A certain 1.b7 acre tract of la� lying in Mockeville '�oMnehip on the ' Weet aide of Jericho Road ad�oining Pa�ha Brown on Lhs South and West, � . ard Ralph Randall and Paritha Broxn on Lhe North and deecribed ae rolloMa: ; BEGIHlRNC at a point in the center of Jericho Road, Ra1pA Rardall aouth- eaat corner and runnlng thence SouLh 35 ds6reea 00 miswtee Weat 200 feet irith the center of said Jericho Road to an iron pin, aew corner; th�n�e North 55 degreee 00 miautes Weet 350 feet paeaing throvgh an iron pin located oa the Meetern right of way line of eaid road to en iroa� nex corner; thence North 35 degrees 00 minutes Eaet 200 fset to an iron, new corner; thence South 55 dogreea 00 mir�utea Eaet 350 teet tio ths poim ard place of SEGINtiING� containing 1.47 acree, more or leea, As eur►ered b� S. L, Telbert� R. S.� Noramber 17, 1971. For back title eee deed from A. T. �ram, Commiaeloner Lo D. N. Hrorn dated October 22, 1936 and recorded in Book 3L, PaBs 3�9. DaTi� Coumy Regietry; Alao aes quit claim deed frno heire oS D, H. Hrorn to Pa�ha A. Hroxn daLed Noirember 8� 1965 and recorded in Book 75� paBe 186, • Davie Countr Ragiatry. STAHPS PAID $1.00 j The above Lnd wu mnveyed W grantor b7.._.»_........--•__.._...._..._�............__�.�..See Book No..._.....�age._._._ . •I TO HAVE AND TO 80LD the doresaid Vact or parcel ot land�nd all pdvllegea and appurtenances thereunW belonging W the sald part.iee...o1 the aecond part an�.ElT.heln and�algo�forevar. � Md tbe w1d parl.__.Y....oi the tlrst par!doeb...rnvenant t6at....»��a....__...�.v1s/��eized ot eaId premiees in fee and ....�3dlA...............__the rlght to convey the ume 1n fee slmple;Wat t6e tame are Sree'from incumbrances;�nd that.._�s..___... wlll wazraat and dlfend the sdd tltle W the sune agalnat the clalms ot all penons whatsoever. • IN TEST[MONY WHEREOF the said partie a_.�ot lha Brst put.thtit}lenuato xt e_........h�nd..a_..... and se�l.............. _.__......_......._._____�._..._____._...._. .___(Sa1) .._p�tiA��la_A1_.Hs4M�1.._.__..�....._.._..._.__.___.(Se.l> I ----.___.....___......_(Seal) ...---..______...__.�_......._..._.._.._.......__.__..._...(Seal) .................._._....._-••-•.._.....�....._.—_.._.._.____._._.(Seal) _._._.» _ ._...._.._.._.._._(3ea1) ....._......_.�__....._(Seat) ...__.._••---•--____.______.�..._.��_._.....»...__.(Se.l) . .........................................._.._..._......_. ' . i +� STATE OF NOSTH CAHOLINA,..._................„....De�ie.._._..._.._._._.�.Couat�r I,..._._.�b� H. EIIight ......._..._....,a Notary Publlc,ot uid County,do heceb�certit� q,.� PauLha A. Brorn (xidox of D, H. Hroxn) granton,each penonally appeared before me tlils day�nd acknowledged lhe acecution of the foxegoing deed o!conve7ance. W1Nese�hand and notarSal seil Uils the lg dey of._.._....___�orember ._._._._,19.71.._.. My commluton explree...�lLF�-tA{bAF...��..»_».»._..,19..��t.. ..Bobb��. 1Cni�ht�..�..�(.OAal.)._.._..._..._..N. P. • STATE OF NORTH CAftOLiNA—Dovie County. The forcgoing certiIlcufe(7q ot.....__.9A��.._�13a,ih.Lca._T{4keT.Y_�11b11G_....._......_._.......__...•__--••-.._�__...._... . , ..............................___._......__._._._.._��Q�D.6�dS_�?Shcl47..._..__...�_._..�..._......__...._..__._...._........__......_._.._.._... ls(0!�)cerlLled to be correct.Thls instn+ment was pzeseated tor reglatraUoa thls..1e___...day oL.._.NOvlabat �_ 19�1....., a111.�.�S.A.M.,�P.49F., and duly morded 1� tho o�ce ot the Regkter ot Deeds ot Davle County,Norih Carollna!n ' Book.„...�.._._._._,Paga..�zT. . J.K SM1TH,REGISTER OF DEEDS Thb the..._..a.��__day ot.._....._.._2lnxamb�.,..„...�,e.D.,in.7i. - _..........._....._.._..�... By:._..._Na� 111tteror � DEPUTY ItEGISTER OF DEED3. � � ThLs lnstrument prepared b�: .____._.....�. _�. �_.�._._.. �.._...... . . -r��- , Jan 25 10 03:11 p Information Services 3367531680 p.2 � . � _�-- • . '�iC�F V�ILUATION�TMPROVEI4IENT PEIZ��IIT�:�'1TC j� �jC (,�jJu'j� � � �' onnn•En�ironmenfal fIealth ��'�/ ��2-/'��"' � . os 8481?]0 Flospita]Street � � C , 2 a n�'�(� locks�'ille,?VC ?.70�8 � ...�� ` ��` � (336), 3-67S�i Fax(336)753-1b84 �� ' / � ��f� _ ic on For. 0 5i�e Ev�lu�ti.> �cemem Per it Cl Auti�or;zatien To Cons[nict(ATC) �th T of A�plicativn: 1 v�5�g�� ` Rcpa:r .uiing System f7Expansion,�]odific�tion uf Gaisting System or Facility ,.n� titi+ ��^�il _ " •l�fPORT�(,�_:•*C!` L[CATION C.�1�'A'OT BB PFGCESSED UrLESS ALL OF TFI�,P�EQUTRED � QRf�IATI ROVIDED. P.efer to tke]?!FO?L�'L'�TION BULLETIN for instruc�ions. APPLiCAVT Il�FORi\1ATIO�I Van,e:o be Billed ��O7�t� �� Contact Person C.1 C.Y� 3il{mgAddress L� '�'�."J `?�`�.,�,�nnM�..,, (� � HamePhonc �' 4: ul"1 �pr i,ity/Siste�Z[P ��►��(3T,��J.�, e�.'�('j"� ��$usinzss Phone ��/- �� Na:ne on PertniVATC ifDi,�'erent than Abovc h1ailin�Addi•ess J_ _ CitylState!Zip_ PROPERTl`INEORi��f\TIQN *Datc Ho�sefFa�ilih•Co-ne-s Flae ed ��1� NqTC: A survey plat or site plan must accompany this application. Included:0 3it:PIa1 OPlat(to scale) (Permit is i�a!id fo 6�montlis wi;h site p)a�i,no espiralion with comple�e p;at.) O«�ner's Name ('�'�(� '(Y�,hQ_ Phonc I�umber - ' Ocvner's Adcress ��, City/State/Zip �VC1n 7 � Prepeny A�idress � Citj��,i_ Let Size�_��Tax Pll�� SubdivisionName(ifa plicablei Section�I,otk� Dtrcctions To�iie: � �.�QpC� �Q�}- � �. r i 1?��-�� ZLy�a�L1Pr ir1 � If thc�ansvier tL any o`Ihe f ltov;inb ue�dons is"Yes",suppoRing documcnwtion must be atiachcd: ,1re tltere nny cxis[ir,o w•ask.watzr s}•s�ems�n U�c si:e? Yes�o D�es the site contair,j�riscictional��etla�ids? �V"es rJJo 1rc J�cre any eascmenls or rigl:t-of-ways on the site? Ycs ./No , ls ihe site suSject to appro��al by another puUiic agency? JYe;.7�ln � � Will wastewatci•edicr than domesCc se�vagc he generated? Yes 7Na IF ftESIDGNCE F1LL OUT THE BOX DELOGV M �Peuple � k Bedrooms �Ba:hr oetis� Garden TubiVlhirlpo�l '' es GNo 8��ement:❑1'es i o Basement Plumbine� CYes o IF NON-RESIDGNC�1'ILL OLTI'TFdF.BOa}3F..1..0��' rT;�pe of Faci IityiTiusiness Tecal 5quaze Foeea;,e of Eiuiiding �Peorle �5inks #Comrnodes u Showers #Urinals ' �stirnated�Valcr Usage(g3llons perda�;i_ (,tt�ch c�aimeniation or:imilar 1'acilit��waler consumptia��j FOODSERVECL ONLY: h Seat� T}•pesys�etnrcqucsfed: e�Conventinnal G:lccep;ed ❑Ir.no�•ative ❑:\i[emat:ve OOt:�er_ Gl'ater Suppl��Type- :Cu�mty!City��+'ater f: e��1�Ne11 �Existing 1�'etl �Cer.miu-�ity�Vell � Du you an�_:cipaic additions ercrpansions ofthe f'aciliry this sysf_m is intendeC io servc?= Yes �V\o [fyes,�c1�at type^ _ This is In ce.vlih;that Uie;nfcrmati�n rrovided oa this epplic�tion is 1n�e and conect ce the Lcs of my kno�+•Eedgr. 1•�nde,-s�.�nd chat ano Pem�i�{s)orp.TC(s)i;sued hereafter are,ubject to suspen�ion ur revocation if thc sitc is al'cred,thc intmtdcd usc charges,o�if��e intomia�ion scbmitied in this applicatinn i;talsificd orc:�angeci. l iurcb>•�rant ri€ht o(��(rq to thc Author��ed � Representative of the L�avie Counry Heatth Department t��cor.duU ncce:sary�inspc�.tiens to de:ennine compliance�tiith applicab6= la�vs a:i�:ulcs. [undcrstand lhat I am responsi�lc for th�proper idcntification and 3abclinS of prop�r[y litles and comcrs and ;;caung,�d 'ageint o akice the Yovscifaciliry locatian,preposed well lou�tiai and�hc lucatinn of ar.:i�U�?r ame�itics. Sitc Rccisit Chargc I Freperty o�vner's or q�v�cr's leesl repre�entalivc;i�n�turc Date(sl: � Clicnt Nrtification L7ate: Datc EfIS: Signgivcn ;_Ycs JPla .�lccount� �D`�l" Reviscd l lil16 1nv�ice'� 7� � � / / \. �.VI\IRVb Vv��.w• �,� \_/ � EIP `�` �_ , ,.�- . 3.7843 ACRES � � S ��1.`f' � �,� � �a� • ��PPB�84� Og•1�. `'� � _,,,, ,_.,. ..._ ��,�,� N�.�r �� £e� Ei�r`� �.-- BOBBY GRANT MINOR � 6,�6?.' .�, �, ��Ne) ` MICKY ANN MINOR Z � \ 0.8. 76 PG. 402 N�� rn Q �.�.�i� 1 �ti �� \ � GARAGE 1.248 ACRES �^�'.,�� .� ' o �/ . � DONNIE LEE ADAMS � N�p HOUSE ��` ' � VICKIE N. ADAMS � UNDER N�P 1 �0.8. 205 PG. 900 ` '' HE � ONSTRUCTION tr� .• 'V 1 :-'� �, .•--''" � �N � �� '' r ./' i �r � o '1 c� `�(�� . _�-4-�ACRE`,...--...i' - / � �'� ��',\1`L ��`C a�� _ �. .�'' O�%�' /" t`\P � � � ,p�"�l � N 88'0 '1 t3"W �� Elp 6�� p . � O 0 SHED NIP 63.2574 32.�9'P F,`'�� RE� �s APPROXI! �apG. PONO COti�MUNi � ''�� G�` /� / .._.._,.�_____...____. � U �/ /,�Z �,....._----•.._---....___- �• o�. c5�• 2 /�5,5'./.. i'' %�-�.�/ h10TE: �,o- ' '�°�o°��F�` /�� ..o��o IRON IN CREEK IS 7.85' OFF LINE. ��i� � � 1 S' :�0�' '1�'P� P120P�R'rY LINE IS IN OISPUTE W I 7 H �s ,, , ��o � 6�j �`�(�� 8088Y GRANT MINOR. � .l MINOR'S DEEO CALLS FOR 7HE LINE j TU RUN WITH LOUIE ZIMMERMAN UNE. CREEK LINDA DENE PI7T'5 ' LOUIE C. ZIMMERMAN'S DEED, D.B. 56 PG. 284, ' ,�g D.g. 743 PG. 700 CALLS F'OR LINE TO RUN FORM STON� TO STONE. � ��`�.LS• �• p,g g PG. 284 TFlACT 2 TH15 IR(JN CREA7ES AN OVERLAP WITH ' � LINOA OENE PITf5 DEEO, D.B. 440 PG. 75 � �� ` �Q I e„��j 5TONE fOUNU \ ��,��P�o N OTE a � G��d� LINDA DENE PITTS \ 1.ZON�NG: RA p.8. 440 PG. 751 \ �,NO NCGS �RID MONUMENTS LOCATED WIl 3.SITE IS LOCATEO WITHIN WS-IV WATERSHI 4.TOTAL AREA 6.4437 ACRES. 5.70TAL 7FtACTS 2. REVISED �'HE PURP05E OF 7HIS REVISION pIVIDE LOT 2 INTO I.OTS 2 AND : . r•' • : � . . � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section � Soil/Site Evaluation APPLICANT TNFORMATION PROPERTY INFORMATION Account #: ,990004006 Tax PIN/EH#: 5798-26-2719 Billed To: Rick MABE Subdivision Info: Reference Name: Location/Address: 407 Zimmerman Road-27006 Proposed Facility: Guest House Property Size: 5+Acres Date Evaluated: Water Supply: On-Site Well � Community Public Evaluation By: Auger Boring .� Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position („ L. Slope % p0 p HORIZON I DEPTH , Q' .. Q Texture grou G � � Consistence �- Structure � �L ,� Mineralo � HORIZON II DEPTH 1. Texture rou Consistence Structure Mineralo HORIZON III DEPTH Texture rou Consistence Structure Mineralo HORIZON IV DEP'TH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE .�.$ . 5 SITE CLASSIFICATION: �S EVALUATION BY: �,r�.t�IN t�Nl(� �b/I/R/�0 LONG-TERM ACCEPTANCE RATE: • � OTHER(S)PRESENT: REMARKS: LEGEND � i.andscape Position , R-Ridge S -Shoulder L-Linear slope FS -Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Tetrace 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 CONSi�TENCE �'I9JS.L 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 Mineralo�v 1:1,2:1,Mixed LYQt.� 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" �r less Classification-S(suitable),PS(provisionally suitable),U(unsuitable) TTAR -T.nna-tPrm a�rantanrP ratr_ aal/�av/ft7 � it � 1 1 � 1 � 1 FR 0,,3 \ 1ao"F 1 3p. � FMF ` 1 AtpJIMMY D. SWAIM 1 D.B. 200 PG. 201 oe ?p3 Ac \ 1 1 SECOND TRACT spy 1 1 IRON SET 4' 0 81e s �•6?'e ror - - - 30' EASEMENT _ _ _ - -_-� _ �5. ^ IRON SET 1 \RON S� 20j j3, — — _ _ — — N 85°36'35"E IRON FOUND _ — — 554.07' / IRONS FOUND N 85°36'36"E 43.30' IRON FOUND DONNIE LEE ADAMS & VICKIE N. ADAMS N D.B. 175 PG. 596 / W RICHARD K. MABE & PENNY M. MABE a / / N D.B. 164 PG. 549 �• �' p z u; 52 5a/ o 9 W LA Ta � •� � N � cv\ �°0,00 o 0.5950 ACRE IRON FOUND IRON FOUND CD IRON S� 00. w 00OA W CREEK pF� 1�01� $ �RAD tJ6 �, S6 oyo ti Gy / 1 .000 ACRE / y° - % N o SITE LOCATION MAP MARY ZIMMERMAN W ! E b'D� Woo STONE FOUND NOTE. 60 0 60 120 180 DASHED LINES FROM SURVEY BY OTHERS. GRAPHIC SCALE — FEET NOTE• %4 CAR••'•� PSN CAA FMAP OR RICHARD K. & PENNY M. MABE THIS LINE IS OR HAS BEEN IN DISPUTE I JOHN RICHARD HOWARD certify that .� •..gTE •s DONNIE LEE & VICKIE N. ADAMS WITH BOBBY MINOR this map was drawn from an actual z ! SCALE I TOWNSHIP COUNTY STATE DATE,s field survey under my direction and f SM 1" — 60' FULTON DAVIE N. C. 9-8-98 supervision, that the ratio of P PART OF D.B. 200 PG. 210 JIMMY D. SWAIM recision is 1 P r •�•'I.,y�gjCNA�,��o''i HOWARD SURVEYING JOB NO. •,, ��•• JOHN RICHARD HOWARD RLS 98030 ~�NINNMN P.O. BOX 276 ADVANCE, N.C. (336) 998-5396 REGISTERED LAND SURVEYOR L-2890 hKPforre i �tion at � o'clockL}_—M. This the�iNu--++ Day of . 206 I and re orded in Plat Book Poge t I _ . 1CAVA Register of Deeds I (we) hereby certify that I am (we are) the owner(s) of the property --��//��►►�� ' described hereon, which is located in the subdivision Jurisdiction of Filing Fee�_Paid. Davie County and that 1 hereby adopt this subdivision pion with my free %01 \ n SITE consent, established minimun building setback lines and dedicate all B streets, alleys, parks, and other sites and easements to public oreputy pr' ate u es noted. County, North Carolina igned v at LOCATION MAP m N 04W— signed Davie Review Officer Date qvmfte /. State of North Carolina County of Davie Review Officer of Davie County, E "I (we) hereby uiderstond that this plat is approved as exempt from the Subdivision Ordinance of Davie ce i y that this map or plat to which this certification / County. This is a family subdivision and is for the exclusive purpose of conveying land among family is affixed meets all statut re uirements for cording. members within to third degree of lineal kinship. These lots/tracts shall not be used for the purpose of sale / or building develoment, either now or in the future, except for those family members. Additional Review Officer / approvals may bi required by Davie County or its successor agency before any subsequent sale or building / / s dslopment may occur.' o e PROVAL �snxtE ,;A� NO REQUIRED BY THE FOUND , JIMMY DALE SWAIM Own kulaho DAVIEPCOUNTY PLANNING DEPARTMENT. SHELLEY JO SWAIM ` s D.B. 474 PG. 776 Owner W Vie Signature Z, MOVER F. SNOW JR. I further ocknorledge that my family members who will be conveyed the newly created family lots ars: PLANNING do ZONING DIRECTOR i 0 MARY W. SNOW 1�0 O.B. 203 PG. 501 / 1. -�� Lot/ and -! 1 (home) (relationship) 2. Loth / Surveyor Certification M- (rel ionship) for Subdivision (ho ` \reI, Doha Richard Howard Professional Lond Surveyor, Number L-2890NIP Elp1 certify to one or more of the following as indicated by on X: a. That the plat is of a survey that creates o subdivision of land within the area of a county or municipality that has on ordinance that S 78.53 NEW EASEMENT 'o'' JIMMY 0. SWAIM regulates parcels of land; p�\ 18 E gg3s6' 1O 1 D.B. 200 PG. 201 b, That this plot is of a survey that is located in such portion of a r,"' ••. o county or municitpolity that a unregulated as to an ordinance that 4 •• 8 N�`1 d, regulates elland;s of thus in asurrvey of Thaton existing parcel or parcels of land; % i^s; (�31ae. P X c. That this is a survey of another category, such as the recombination of •., y�, �. r, , existing parcels, a court—ordered survey or other exception to the ' �p 1 definition of a subdivision; CCS' e. That the information available to this surveyor is such that I an unable ' 1 1 to make a determination to the best of my professional ability as to provisions contained in a. through d. above. HOUSE ��l' •.• NP 30' EASEMENT 2 y crCORNS -- .__ O.B. 184 PG. 518 — —_ `— —— — — ^ __` Signature L-2890 D.B. 164 PG. 546 surveyor S D.B. 164 PG. $49 _ 1-7 ` _ E1P � Davie County, North Carolina 3.7843 ACRES �'F, e 3 ~e w i 81.84. B 1?"E -- —— — — — --' r ---4 1 X15' o N� 4g `~ 1 N,85!36" 7.37 BOBBY GRANT MINOR $.g�`• up ( nE UNE ) MICKY ANN MINOR t� y6�•' ��'• �,ed�r' r, N "'E e j �" / ak CA R, D.B. 76 PG. 402 Z ` DONNIE LEE ADAMSHIP VICKIE N. ADAMS D.B. 175 PG. 596 0% 1.2 ►� �,y•�9h , $ �..� �1— :=EAi_ HOUSE 1.248 ACRES �'�� t' K EIEN ADAMS ADAMS LEE HOER h N D.B. 205 PG. 900 HE Z ONSTRUCTK)NNIP SUR"... } (4 N \ `acA. �� PREMINARY PLAT FORUREVIEW ONLY ONLY 9'Cf IA1;01� N �9ti1.4114 ACRE_• ..itz. N 88'O1'f3"W � 6��3 "W I John Richard Howard certify that this plat was drown under my supervision 95'7 p0'0� from on actual survey made under my supervision (description recorded in SHED Nin 63.25' 32.49' APPROXIMATE FLOOD UNE S� / �Z COMMUNITY PANEL NUMBER 3710578800K Deed Book ,Page or Plot Book ,Page if applicable); �' / / POND CREEK that the boundaries not surveyed are clearley indicated as drown from information found as indicated; that the ratio of precision as calculated .//1 _.._.. _. � �•pd,. /// b�,b�•,� •--- --••—•—..,. is 1; 2000.A ; that this plat was prepared in accordance with G.S. 47-30 as amended. Witness my original signature. Registration number and seal NOTE. ��d'u�OG1' This the 2 Day of JULY , 2015 IRON IN CREEK IS 7.85' OFF LINE. PROPERTY UNE IS IN DISPUTE WITH S BOBBY GRANT MINOR. �� / MINOR'S DEED CALLS FOR THE UNEf Professional Land Surveyor NO. L 2890 TO RUN WITH LOUIE ZIMMERMAN UNE. /I LOUIE C. ZIMMERMAN'S DEED, D.B. 56 PG. 284, Davie County, North Carolina LINDA DENS PI CALLS FOR UNE TO RUN FORM STONE TO STONE. 1� THIS IRON CREATES AN OVERLAP WITH �,'Lb' D.B. 743 PP.B 9 PG. 2284 TG. 70TRACT 2 S LINDA DENE PM DEED, D.B. 440 PG. 751. LEGEND Q Qfis STM FOUND \ POWER UNE 100 0 100 200 300 �° NOTE: - _ LINDA DENS PITTS — peppc/.oNu GRAPHIC SCALE FEET O.B. 440 PG. 751 12ONING: RA — — — FLOOD LINE 2.NO NCGS GRID MONUMENTS LOCATED WITHIN 2000'. PROKIM UND MAP RICHARD K. & PENNY M. MABE 3.SITE IS LOCATED WITHIN WS—N WATERSHED. 4.TOTAL AREA 6.4437 ACRES. Nr 1/2 INCH NM VON PIPE FOR 5.TOTAL TRACTS 3. E>P EN STING wON A STONE SCALE = TOWNSHIP COUNTY STATE DATE'S REVISED PP POWER PatF 1" = 100' FULTON DAVIE N.C. 5-14-09 THE PURPOSE OF THIS REVISION IS TO RECOMBINATION of O.B. 164 PG. 549 AND D.B. los PG. 901 2_23_10 DIVIDE LOT 2 INTO LOTS 2 AND 3. REVISION OF P.B. 10 PG. 87 CREATING LOT 3 6-30-15 REVISED 6-30-15 HOWARD SURVEYINGJ09010 JOHN RICHARD HOWAARDRDPLS TO ADD SEPTIC FIELD FOR LOT 3 ON LOT 2. P.O. BOX 276 ADVANCE. N.C. (336) 998-5396