154 Windemere Drive Lot 10 Davie County,NC _ Tax Parcel Report Thursday, February 23, 2017
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WARNING: THIS IS NOT A SURVEY
77
Parcel Information 3
Parcel Number: F8020A0010 Township: Shady Grove
NCPIN Number: 5870692151 Municipality:
Account Number: 82515135 Census Tract: 37059-803
Listed Owner 1: SUMMERS DAVID LEE Voting Precinct: WEST SHADY GROVE
Mailing Address 1: 154 WINDEMERE DRIVE Planning Jurisdiction: Davie County
City: ADVANCE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27006-7887 Voluntary Ag.District: No
Legal Description: LOT 10 WINDEMERE FARMS SECTION ONE Fire Response District: ADVANCE.
Assessed Acreage: 0.74 Elementary School Zone: SHADY GROVE
Deed Date: 7/2000 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 003390293 Soil Types: GnB2,GnC2
Plat Book: 0007 Flood Zone:
Plat Page: 103 Watershed Overlay: DAVIE COUNTY
Building Value: 179510.00 Outbuilding&Extra 3470.00
Freatures Value:
Land Value: 29000.00 Total Market Value: 211980.00
Total Assessed Value: 211980.00
161 AlldataIsprovided as Is without warranty or guarantee of any kind either expressed or Implied including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie Countys GIS website shall hold harmless the
County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to
NC or arising out of the use or Inability to use the GIS data provided by this website.
'` 0PERATIO N'PERMIT or lice Use 0517
' Davie County Health Department *CDP File Number 196686-1
210 Hospital Street
P.O. Box 848 County ID Number.
Mocksville NC 27028 Evaluated For. REPAIR
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Amy Summers rAddress:
operty Owner. Amy Summers
Address: 154 Windemere Farms 154 Windemere Farms
Cty: Advance ty: Advance
State2ip: NC 27006 State/Zip: NC 27006
Phone#: (336)940-3644 Phone#: (336)940-3644
Property Location & Site Information
Address/Road#: Subdivision: Windemere Farms Phase: Lot: 10
154 Windemere Drive
Advance NC 27006 Directions
Structure: SINGLE FAMILY 154 Windemere
#of Bedrooms: 3
#of People: 4
*Water Supply: wA
*IP Issued by. 'System Classification/Description:
TYPE 111 G.OTHER NON-COW.TRENCH SYSTEMS
*CA issued by: 2140-Nations,Robert
Saprolite System? (,7 Yes QNo
Design Flow: 3 6 0Distribution Type: GRAVITY-SERIAL Pump Required?
Soil Application Rate: QYes sNo
0 3 *Pre Treatment:
Drain field
Ni
trification Field 1 a _ 0 0 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD
rain Lines 3 Installer. Brian McDaniel
Total Trench Length: 3 0 0 8• Certification#: 1118
Trench Spacing: _ 9 Inches O.C.
Feet O.C. *EHS: 2140-Nations.Robert
Trench Width: — 3 Oln tes
Date: 0 - / 0 9 / 2 0 1 7
Aggregate Depth: inches
Minimum Trench Depth: 3 6 Inches
77 77)
Minimum Soil Cover. 4 Inches Approval Status
Maximum Trench Depth: 3 6 ® A roved CI .Disa roved r
In pP
Maximum Soil Cover: a 4 Inches
CDP File Number 196686 - 1 Septic Tank County ID Number:
Manufacturer. Lat.
Long:
STB:
Gallons: Installer
Date: / Certification#:
*EH S:
*Filter Brand:
ST Marker. El Yes El No
Date:
Reinforced Tank: El Yes El No
Approval Status
� Piece Tank: ❑ Yes ❑ No ❑."Approved❑ Dlsapprovetl
Pump Tank
Manufacturer Installer.
PT: Certification#:
Gallons: *ENS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeght: ❑ Yes ❑ No (Min.6 in.)
Approval Status
einforcedTank: ❑ Yes ❑ No ❑ Approved❑ Disapproved
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer.
CPie Length: feet Certification#:
*EH S:
*Schedule:
Pressure Rated ❑ Yes ❑ No Date: /
Approved fittings [I Yes ElNo Approval Status
❑:.Approved❑ Disapproved
eu
Pump Type: Installer.
Dosing Volume: — Gal Certification#:
Draw Down: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ NO
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ NOApproaralStatusw ,
PVC unions ❑ Yes ❑ No = ❑ Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ YeS ❑ NO
CDF;File Number 196686 " 1 County ID Number:
Electric Equipment
NEMA4X Box or Equivalent ❑ Yes ❑ No Installer.
Box 12 inches Above Grade ❑ Yes ❑ NO
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Approval Status
Alarm Audible El Yes ❑ No p Approved El Disapproved
Alarm Visible ❑ Yes ❑ NO
2140•Nations,Robert
*Operation Permit completed by:
Authorized State Age t. Date of Issue: 0 a / 0 9 / a 0 1 7
Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal,15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE III G. sewage septic system.
Rule .1961 requires that a Type TYPE III G. septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: N/A
Management Entity: OMER
Minimum System Inspection/Maintenance Frequency ByCertified Operator.
NIA
Reporting Frequency By Certified Operator NIA
Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator for the life of the septic system.
Rule ,1961 requires that Type VI septic systems designed fora homelbusiness owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the
system is in use,and other requirements for the continued proper performance of the system. It shall also be a condilion of
the Operation Permit that subsequent owners of the systems execute such a contract.
Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.** �;
OPERATION PERMIT 196686'- 1
Davie County Health Department CDP File Number:
210 Hospital Street
County File Number:
P.O.Box 848
Mocksville NC 27028 Date:
0Inch
Dravviin Drawing Type: Operation Permit Scale: . OB
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CONSTRUCTION pi�Q� FICDPFile
or Office Use Only
AUTH6RIZA11ON I mber 196686 1
�Davie Coun Health Department I umber.
1. 210 Hospital Street Evaluated For: REPAIR
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 1 / 1 8 / a 0 a a
Applicant: Amy Summers Property Owner: Amy Summers
Address: 154 Windemere Farms Address: 154 Windemere Farms
City: Advance City: Advance
StatefZip: NC 27006 Statefzip: NC 27006
Phone#: (336)940-3644 Phone#: (336)940-3644
Property Location & Site Information
Address/Road #: Subdivision: Windemere Fauns Phase: lot: 10
154 Windemere Drive
Advance NC 27006 Directions
Structure: SINGLE FAMILY 154 Windemere
#of Bedrooms: 3
#of People: 4
��*Wat�erSurply: NIA
System Specifications
Minimum Trench Depth: 3 6
rDesigan
ssification: Provisionally Suitable Inches
Minimum Soil Cover, a 4 Inches
e System? . OYes QNo
low: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 3 Maximum Soil Cover: a 4
Inches
'System Classification/Description: 'Distribution Type: GRAVITY-SERIAL
TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS Septic Tank:
Gallons
'Proposed System: 25%REDUCTION 1-Piece: OYes ONo
Pump Required: OYes QNo OMay Be Required
Nitrification Field 1 a 0 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece:OYes ONo
Total Trench Length: 3 0 0 ft GPM vs— ft. TDH
Trench Spacing: 9 Qlnches O.C.
— Feet O.C. Dosing Volume: _ Gallons
Trench Width: 3 @Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre Treatment: QNSF QTS-1 QTS-II
Septic Tank Installer Grade Level Required: 01011 Q 111 Q IV
Donn 1 of Q
CDP File Number 1966$6 - 1 County-ID Number.
❑ Open Pump System Sheet
Repair System Required:OYes ONO ONO, but has Available Space
rDesign
System Trench Spacing: Q inches 0. .
ification: o Feet O.C.
w: Trench Width: _ _ _ _ S Feet Inches
Soil Application Rate: Aggregate Depth: inches
___..
*System Classification/Description: Minimum Trench Depth: Inches
Minimum Soil Covet
Inches
'Proposed System: Maximum Trench Depth: Inches
Maximum Soil Cover:
Nitrification Field Sq. Inches
ft.
No. Drain Lines *Distribution Type:
Total Trench Length: Pump Required: OYes ONo ()May Be Required
Pre Treatment: ONSF OTS-1 OTS-11
"Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization forWastewater System Construction shall bevalid for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be Issued at the same time the Improver ent Permit issued(NCGS 130A-336(b)� If the Installation has not been
completed during the period of validity of the Consouctlon Permit,the Information submitted In the application for a permit or Construction
Authorization is found to have been Incorrect,falsified or changed,or the site is attered,the permit or Construction Authorization shall become
Invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps.Signature Required? OYes ONO
Applicant/Legal Reps. Signature* Date:,
*Issued By: 2140-Nations.Robert Date of Issue: 0 1 1 8 - a 0 1 7
Authorized State Agent: Malfunction Log OYes
OHand Drawing Olmport Drawing
**Site plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 196686 - 1
• Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number.
Mocksviile NC 27028 Date: 0 1 / 1 8 / x 0 1 7
Q Inch
Drawing Drawing Type: Construction Authorization Scale: . O /A
ON
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CONSTRUCTION AUTHORIZATION •
Davie County Health Department
210 Hospital Street CDP File Number: 196686 - 1
P.O.Box 848
Mocksville NC 27028 County File Number.
Date: 01 / 1 8 / 2 0 1 7
Click below to Import an Image from an external location: Drawing Type:Construction Authorization
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Plinnitta s «.; DAVIE COUNTY HEALTH DEPARTMENT
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t+ Environmental Health Section PROPERTY INFORMATION
/ P.O.Box 848 j -
Directions to property: + 1 !6 >v4ocksville,NC 27028 Subdivision Name: l"`d 1 1,,1 i's'' ' f r �" r
} Phone#:336-751-8760
Section: Lot: ( .:
AUTHORIZATION FOR _
WASTEWATER
J '_ �r ��
q C ,• ►1't i r (Ca �/ �"1Tax Office PIN:#
SYSTEM CONSTRUCTION
003146 t � ` t ,/,,, r /i, r D (1C ,'6
AUTHORIZATION NO: 1� Road Name Zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS,
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED /
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS-5 #BATHS ! #QCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
1 / �- Y1 4,
LOT SIZE Li TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) (/�� NEW SITE REPAIR SITE j'd
C, yI
SYSTEM SPECIFICATIONS: TANK SIZE {) GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LI.EAR FT.
OTHER 7
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
SPr:a��t
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(, C'►'}� ��� � i 1,x.1 t`'f" t r� �'� C �!� ✓ �. � ! V
,A s~� c,1 o u C ( � 1 H G •� ' Icy r i.+� `I c^c-
FOR FINAL INSPE ION OF THIS SYSTEM PLEASE CALL BETWEEN :30-9:30 A.M.ON THE DAY OF INS T LLATION.TELEPHONE#IS(336)751-8760.
PERATION PERMIT p '
I(- J]� 4 C, O 1" SYSTEM INSTALL BY:
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A ORIZATION NO. OPERATION PERMIT BY: 7;as%% DATE: V 71-7-16
**1rHE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I i 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.
DCHD 02102(Revised)
�� � . ter.' �'�� .�� 4-i� '�.i.,. ,..--,; x• .:. ./ i �' ly _ 1' w�" '� :,.. .
Px ttee'`s: }- - �DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
• _ r" P.O. Box 848
Directions to property: f" U. Mocksville,NC 27028 Subdivision Name: � '`s " !6 �` I ' ' ''
Phone#:336-751-8760 '
Lot:
Section:
r AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 003046 A Road Name- ` , ' `` r "� 1 ' , u 1zip:
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
r', +"r -• { �' , IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE J #BEDROOMS H�#6THS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE �L'1 I TYPE WATER SUPPLY rt DESIGN WASTEWATER FLOW(GPD)) tr' NEW SITE } REPAIR SITE V'
SYSTEM SPECIFICATIONS: TANK SIZE t `C. GAL PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH i LI EAR FT. 1
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENTPERMITLAYOUT `
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FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION TELEPHONE#IS(336)751-8760.
OPERATION PERMIT
1 `. SYSTEM INSTALLE BY: t l n
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AUTHORIZATIt NO. 1 " �/ O1RATION PERMIT BY: -t(!r'/ �/f�� r' DATE:
--THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED�B�OVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL,S)CSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF MIME. ,
�+ DCHD 02/02(Revised) L�.�
Davie County Health Department
4 s E. amental Health S,
iL P.O. Box 848
0U 210 Hospital Street f P-0 4Courier# : 09-40-0 'SEP Mocksville, NC 270
`�-
_
Phone:(336)-7 -6780 ENVIRONMENTAL HEALTH Tax:(336)-751-8786
- WASTE4ATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name: Z Phone Number 3 '-WO (Home)
Mailing Address: /.ice �ct✓�r�',e�f/,2 , IU/o239-Wa-3 (Work)
I&W /0
D led Directions To Site: &,/ /0 .Dl���aldlic AXA/ V__j
re, &Q tq4s
Property Address: r:�'ne
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: &: j A/1+117f/,� Type Of Facility: ( SLS
Date System Installed(MondMate/Year): 51/Z/00 Number Of Bedrooms:__3 Number Of People:
Is The Facility Currently Vacant? Yes & If Yes,For How Long?
Any Known Problems? Yes 0 If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: CAS Number Of Bedrooms: Q Number of People Ca
Requested By: Date Requested:��o
(Signature)
For Environmental Health Office Use Only
Apmproved Disapproved
oments: e aG
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 limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order #_ 2!7 Amount:$ 00.00 Date:
Paid By:
D,SA ft fS Received By: - ql14
Account#: Invoice#: !
\ , DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900259 Tax PIN/EH#: 5870-69-2151
Billed To: David Mallard Subdivision Info: Windemere Farms Lot#10
Reference Name: David Mallard Location/Address: Beauchamp Road-27006
Proposed Facility: Residence Property Size: 3/4 Acre
ATC Number: 2264
**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 INSTALLING SYSTEM.
Residential Specification: Building Type NDX-Na #People #Bedrooms 3 #Baths :2.�
Dishwasher: FT Garbage Disposal: d Washing Machine: If Basement w/Plumbing: ❑ Basement/No Plumbing:
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 13
Lot Size Type Water Supply ODNTY Design Wastewater Flow(GPD) ' (E � Site: New Repair 11
System Specifications: Tank Size 100 GAL. Pump Tank GAL. Trench Width :W Rock Depth J Linear Ft. —'ZXD'
Other: S'r et P_%>-r, -jr�-X,xg I-&Lt_ C,��GS 9 rte•c•
Required Site Modifications/Conditions: IS'UFF Roost-
L,Ir
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER AISER(S)IF 6 K 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 p.m.to 1:30 p.m.on the day of installation. Telephone#is(336)751-8760.****
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Environmental Health Specialist's Signature: Date:
DCHD 05/99(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.Boz 848/210 Hospital Street
MockvAlle,NC 27028
(336)751-8760
Account #: 989900259 Tax PIN/EH M 5870-69-2151
Billed To: David Mallard Subdivision Info: Windemere Farms Lot#10
Reference Name: David Mallard Location/Address: Beauchamp Road 27006
Proposed Facility: Residence Property Size: 314 Acre
ATC Number: 2264
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 WASTE W R CO IS VAL FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: at
CERTIFICA COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the s described on Improvement/Operation Permit
has been installed in compliance with Ari lP apter l A,Section.1900"Sewage Treatment and
Disposal Systems,"but shall in NO WAY be taken as a antee at the system will function satisfactorily for any
given period of time.
U
Septic System Installed By:
Environmental Health Specialist's Signature: ��/� Date:
DCHD 05/99(Revised)
•, •, APPIJCATICIN FOR
Davie County ealth Department
PERMR&ATC'
Envlrontnenhil Heaft Serdifon D V L�
8.0. Bo: 848/210 Hospital Street NOV 1 8 1999
Mockaville, NC 27028
(336)751-8760 - '.
***ZMPCRTANT*** THIS APPLICATION CAM= ffi PW=SSW UNLESS ALL
INSORbATION 18 PROVIDED. Refer to the INFORMTION BULLETIN for i1n�Sstruetions.
1. hams to be Billed / J.4 0 7-d S, %�fi4L1��� contact Person 4fl/
Wailing Address/ao E;a77•f:dI z 6- atm*SPS`. q =7 9 77
City/state/SZP Zew;Sy Business Phone 97,4^ To? 9-10-r
Z. Hams on Permit/ATC if Different than Above
Wailing Address City`/State/Sip
3. Application For: �_ t�imSite evaluation provement Permit/ATC 0 Both
4. System to service: J.House 0 Mobile Home 0 Business 0 Industry O Other
5. If Residence: # People # Bedrooms -�' # Bathrooms
Dishwasher AGarbage Disposal )J Mashing Watkins 0 Basemsnt/Plusbing Vbassmanthlo Plumbing
6. ze Business/industry/other: Specify type # People # Sinks
# Commodes # Showers # Vrinals # Mater Coolers
IF FOODSERVICE: # Seats Estimated hater Usage (gallons per dale)
7. Type of Mater supply: County/City 0 Well 0 Community
a. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes /T No
If yes,what type?
***IMPORTANT"**CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST RESUBMITTED by the client with THIS APPLICATION.
Cay-� r3i-�
Property Dimensions: ,��, �Sl-{2 WRITE DIRECTIONS(from Mocbville)to PROPERTY:
Tax 0111ce PIN: # j;270 -6 5-1 1f l-5 E-f�st (5e -'e*
Property Address: Road Name 477- �✓% ��l `J PAy� it to
3
Citylzipe-
lf in a Subdivision provide information,as follows:
Name: Al e"lo-leee,
Section: Block: Lee. Date Property Flagged:
Tble Is to certify that the information provided Is correct to the best of my knowledge. I understand that any permit(s)
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 fi dsifled or changed 1,also,understand that I ant responsible for aft charges Incurred frons
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 suitab
DATE //l_/ 9 % SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include a o h following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
/ 3 I Site Revisit Charge
H t Notification Dste:
o o'zs EHS:
Account No.
Revised DCH((+B7 4 fad �� n Invoice No. /
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- DAVIE COUNTY. NORTH CAROLINA
I)ER 10.\1996, 1
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i .• APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT TG'RR---
-�' Davie County Health Department 15 �
Environmental Health Section
P.O.Box 848 .UN 10 QW
Mocksville,NC 27028
(704)634-8760
EIIVIROmlEtIAL IIEAtri
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSEDIUNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed J c��sRl/i z°k1 D ,V"ew�l- Contact Person h44 , PA 9��
Mailing Address 3 171 U d&e,11/ /a ,D Y, Home Phone
City/State/Zip 4ezv Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: El""Site Evaluation ❑ Improvement Permit&ATC ❑ Both.
4. System to Serve: ❑ House ❑ Mobile Home O Business O Indus�b,1, ❑ Other e'
of
5. If Residence: # People # Bedrooms {' 1 # Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage(gallons per day)
7. 'type of water supply: O'County/City' ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? O Yes ❑ No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: S 1 WRITE DIRECTIONS(from
��7� - - Q 1 Mocksville)TO PROPERTY:
Tax Office PIN: # � 1 I
i l4 S U' G��` d 1✓
Property Address: Road Name l4tl r ,,r� 1
1 Ni'1-��,E,V' ���✓� r3 rd
cityfzipy A ei! N_2 . 07H�
1 �
1
If in Subdivision provide info ti n,as follows:
O (a61 1
Name: M.-I Lot #: �2
[.°J,1 P,e�' A2
1
Section: 1
1
This is to certify that the information provided is correct to the best of my knowledge.I understand that any permit(s)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 am responsible for all charges incurred from this application.I,hereby,give consent to
the Authorized Representative of a 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.
4 44
DATE SIGNATURE
Revised DCHD(06-96)
n.V. 1b �
4
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT,
Soil/Site Evaluation
APPLICANT'S NAME l/G�� 1/tPLcr DATE EVALUATED
PROPOSED FACILITY / PROPERTY SIZE
ROAD NAME 3� /
n Ae4kAGn a
SUBDIVISION ,�
Water Supply: On-Site Well Community Public L�
Evaluation By: Auger Boring Pit ze!!::� Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Sloe%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
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 i
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H.-Head slope
Texture
S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
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(01-90)
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