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1200 Woodword Rd Davie County,NC Tax Parcel Report Tuesday, December 20, 2016 --------------- '16 1 ---- - ---�461 a' 458 1200 �f f 1212 f � 1 00 y r 436 ,/ ter• ' 1, 1211 ,..___l..__._._.._-__.___-......_.:...:............._......_-_.........-_. WARNING: THIS IS NOT A SURVEY ParcehIriformation" Parcel Number: G400000063 Township: Mocksville NCPIN Number: 5830044118 Municipality: Account Number: 8307178 Census Tract: 37059-806 ... Listed Owner,1:-' WESOLOSKI JOSEPH E Voting Precinct: CLARKSVILLE Mailing Address 1:-:-- 1200 WOODWARD ROAD Planning Jurisdiction: Davie County City:. MOCKSVILLE- Zoning Class: DAVIE COUNTY R-A State:: NC Zoning Overlay: Zip Code: .: - 27028 Voluntary Ag.District: No Legal Description:- LOT 4 CRNA ACRES Fire Response District: WILLIAM R.DAVIE Assessed Acreage: 1.06 Elementary School Zone: WILLIAM R DAVIE Deed Date: - - 11/2016 Middle School Zone: NORTH DAVIE Deed Book/Page: 010350715 Soil Types: GnB2 Plat Book: 0009 Flood Zone: Plat Page: 062 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding&Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: 161 All data is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to thDavie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmleses the rCounty of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to NCor arising out of the use or inability to use the GIS data provided by this website. t Irl 05qh Ul�56l o Sl�c OPERATION PERMIT r�u/ `lor ice se nv ,.. Davie County Health Department *CDP File Number 201626-1,; 210 Hospital Street 583004418 P.O. Box 848 County ID Number: Mocksville NC 27028 Evaluated For.,NEW Phone:336-753-6780 Fax:336-753-1680 Township: Applicant: Abee's Clearing amd Grading r perty Owner: Larry G. Cope Address-. 2381 US Hwy 64 W dress: PO Box 1160 City: Mocksville Y: Cooleemee StatefZV NC 27028 State2ip: NC 27014 . . Phone#: (336)492-2089 Phone#: Property Location & Site information Address/Road #: Subdivision: Cana Acres Phase: Lot: 4 1200 Woodward Road Mocksville NC 27028 Directions SINGLE FAMILY Hwy'601 N, right on Cana Right on Woodward Structure property on left of Bedrooms: 3 #of People: *Water Supply: PUBLtc *System Classification/Description: *IP Issued by. TYPE III B.SYSTEM!WISINGLE EFFLUENT PUMP *CA issued by: 2140-Nations.Robert Saprolite System? Oyes fiD7No Design Flow: 3 6 0 *Distribution Type: PUMP TO GRAVITY Pump Required? @Yes ONo Soil Application Rafe: - a 7 5 *Pre Treatment: Drain field rNo. on Field 1 3 0 9 Sq. ft. *System Type: BIDIFUSER STANDARD n Lines 3 Installer: Tim Abee Total Trench Length: 3 3 0 ft. Certification#: 1011 Trench Spacing: _ 9 21nches O.C. Feet O.C. EH S: 2140-Nations.Robert Trench Width: _ 3 Inches Feet Date: 1 0 / 1 0 / 2 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover, 2 4 Inches Approval,Status` Maximum Trench Depth: 3 6 Inches ® Approved 0. Disa'pprovedz Maximum Soil Cover: 4 Inches CDP Fite Number 201626 - 1 Septic Tank County ID Number: 3004418 Manufacturer. Shoaf Lat. STB: 760 long: . Gallons: 1000 Installer. TimAbee Date: 0 7 / 1 1 / .2 0 1 6 Certification#: 1011 *EHS: 2140-Nations,Robert *Filter Brand: POLYLOK PL-122 With Pipe Adapter ST Marker. ❑ Yes El NO Date: 1 0 / 1 0 / 2 0 1 6 Reinforced Tank: ❑ Yes ... ® No = Approvaltatus Piece Tank: ❑ Yes [ No Approved❑" Disapproved Pump Tank Manufacturer, Shoal Installer: Tim Abee PT: 363 Certification#: 1011 -Gallons: 1000 *EHS: 2140-Nations,Robert Date: 0 7 / 1 1 / :a 0 1 6 Date: 1 0 / 1 0 / . 0 1 6 Riser Sealed E] Yes ❑ No Riser Height:-E] Yes ❑ 'No (Min.6 in.) Approval Status Reinforced Tank: ❑ Yes - Cl No ` © Approved❑,.Disapproved ® Yes , ❑_No 1 Piece Tank: Supply Line FPipe e Size: a inch diameter Installer: Tim Abee Length: 1 1 3 feetCertification#: 1011 *EHS: 2140-Nations,Robert Schedule: 40 Pressure Rated p Yes ❑-No Date: 1 0 1 0 / x 0 1 6 Approved fittings ( .Yes ❑ No Approval Status ® Approved❑ Disapproved U euieet Pump Type: Zoeler Installer: Tim Abee Dosing Volume: - Gal Certification#: 1011 Draw Down: Inches *EHS: 2140-Nations,Robert *Chain: ROPE Date: 1 0 / 1 0 / x 0 1 6 Valves Accessible 0 Yes ❑ No Flow Adjustment Valve F-1 Yes ❑ No Check-valve Yes ❑ No Approval Status PVC unions p Yes El No ® Approved❑ Disapproves! Vent Hole [J Yes ❑ No Anti-siphon Hole p Yes ❑ NO COP File Number 201626 - 1 County ID Number: 583004418 Electric Equipment NEMA4XBox orEquivalent 0 Yes ❑ No Installer: Tim Abee Box 12 inches Above Grade Q Yes ❑ No 1011 Certification#: Box Adj.To Pump Tank Q Yes ❑ No Conduit Sealed 2 Yes ❑ No 'EHS: 2140-Nations,Robert Pump Manually Operable p Yes ❑ No Date: 1 0 1 0 x 0 1 ti "Activation Method:PIGGYBACK / / Approval Status Alarm Audible (] Yes_ _ ❑ NO _ ® Approved❑ Dlsapptaved� ; = Alarm Visible ® Yes ❑ No 2140-Nation,Robert *Operation Permit completed by: - ___Authorized State Agent Date of Issue: 1 0 / 1 0 / 2 0 1 6 Owner/Applicant Signature: This system has been installed in 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 B. sewage septic system. Rule.1961 requires that a Type TYPE III B. septic system meet the following criteria: Minimum System Review By The local Health Department: sYRs. Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: WA _ Reporting Frequency By Certified Operator:NIA Rule .1961 requires that a Type 1V 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 for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the fife 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 owner and certified operator are the same. The contract shall require specific requirements for maintenance 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 condition of the Operation Permit that subsequent owners of the systems execute such a contract. @Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT 201626-1 Davie County Health Department CDP File Number: 210 Hospital Street - 583004418 P.O.Box County File Number: Mocksville NC 27028 Date: Q Inch Scale: . OBlock Drawing Drawing Type: Operation Permit ON/A I - I � r I:_gib QD f L I I _a , S 1 ! t CONSTRUCTION Lor Office use Only AUTHORIZATION *CDP File Number 201626- 1s Davie County Health Department County ID Number:583004418 210 Hospital Street Evaluated For. NEW P.O. Box 848 '�,V...r• Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 4 / 1 5 / a 0 a 1 Applicant: Abee's Clearing amd Grading Property Owner: Larry G. Cope Address: 2381 US Hwy 64 W Address: PO Box 1160 City: Mocksville City: Cooleemee State/Zip: NC 27028 State/Zip: NC 27014 Phone#: (336)492-2089 Phone#: Property Location & Site Information Address/Road#: Subdivision: Cana Acres Phase: Lot: 4 1200 Woodward Road Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy 601 N, right on Cana Right on Woodward property on left #of Bedrooms: 3 #of People: *Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rDesign ssification: Provisionally Suitable Inches System? Minimum Soil Cover: 1 a y O Yes (9 No Inches low: 3 6 0 Maximum Trench Depth: a 8 Inches Soil Application Rate: 0 4 7 5 Maximum Soil Cover: 1 6 Inches *System Classification/Description: *Distribution Type: PUMP TO GRAVITY TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Septic Tank: 1 0 0 Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes ®No Pump Required: O Yes O No ®May Be Required Nitrification Field 1 3 0 g Sq.ft. Pump Tank: 1 0 0 0 Gallons No. Drain Lines 5 1-Piece: OYes ®No Total Trench Length: 3 a 7 ft GPM--vs-- ft. TDH Trench Spacing: O Inches O.C. _ g ®Feet O.C. Dosing Volume: Gallons Trench Width: _ 3 OInches ®Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-1 OTS-11 Septic Tank Installer Grade Level Required: 01011 O 111 01V Page 1 of 3 •58300448 ' CDP File Number 201626 - 1 County ID Number: J ❑ Open Pump System Sheet Repair System RequiredA Yes ONO, ONO, but has Available Space CDesign System Trench Spacing: Q Inches O. . fication: Provisionally suitable — 9 ®Feet O.C. Trench Width: Inches w: 3 6 0 - 3 Feet Soil Application Rate: 0 a 7 5 inches .� Aggregate Depth:Minimum Trench Depth: a 4 *System Classification/Description: Inches TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover: 1 a Inches Maximum Trench Depth: a 8 *Proposed System: 25%REDUCTION Inches Nitrification Field 1 3 0 9 Sq.ft. Maximum Soil Cover: 1 6 Inches No. Drain Lines 4 *Distribution Type: PUMP TO GRAVITY Total Trench Length: 3 a 7 ft Pump Required: Oyes O No 0 May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Characters 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. R m�g 2000 This Authorization for Wastewater System Construction shall be valid 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 Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been completed during the period of validity of the Construction 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 altered,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? O Yes ONO Applicant/Legal Reps. Signature- Date: *Issued By: 2140-Nations,5qert Date of Issue: 0 4 / 1 5 / a 0 1 6 F 000, Authorized State Ag t: Malfunction Log OYeS a Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION 201626 - 1 Davie County Health Department CDP File Number: 210 Hospital Street 583004418 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 04 / 15 / .1016 O Inch Drawing Drawing Type: Construction Authorization Scale: , , , 00 Mock ft. ...................................I..................................,.............................................. .................,................................................. ......... ......... ........ ......... ......... ......... 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Page 3of3 P1 P2 CONSTRUCTION AUTHORIZATION ' Davie County Health Department ( 3 210 Hospital Street CDP File Number: 201626 - 1 P.O.Box 848 583004418�� � Mocksville NC 2�o2s County File Number: Date: .0.4./.1.5. /_2.0.1.6. �1L -T — Ce P�o L�a� mak- 7 CaCClick below to import an image from an ext l ocation: Drawing Type:Construction Authorization c LOT b V �V M a s Page 3 of 3 P1 P2 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC PAID Davie County Environmental Health P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax(336)753-1680 Cc W4b Application For: ❑Site Evaluation/Improvement Permit ❑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 THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed,>•-tn/bQ.S I.IQGirA I-rep ,nn_ Contact Person Billing Address,'3lg1 1_f S 44ukr a4- W Home Phoned 310 a-�O$q City/State/ZIPMCC(twillc-, IVIG a70aR Business Phone -J0q--o13q- 3La 93 Name on Permit/ATC if ii erent than Above±)ep► W less` Mailing Address 31 t City/State/Zip a?03 PROPERTY INFORMATION *Date House/Facility Comers Flagged NOTE: A survey plat or site plan must accompany this application. Included: ❑Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan,no expiration with complete plat.) Owner's Name Phone Number Owner's Address City/State/Zip(f-r-,,pp,.c-.,Q ti IVIG Property Address QDn 14, Cityj�I1� Lot Size Tax PIN# Sq Subdivision Name(if applicable) Section/Lot# Directions To Site: O If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes KNo Does the site contain jurisdictional wetlands? ❑Yes XNo Are there any easements or right-of-ways on the site? C3 Yes KNo Is the site subject to approval by another public agency? SYes❑No Will wastewater other than domestic sewage be generated? ❑Yes No IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms #Bathrooms Garden Tub/Whirlpool❑Yes KNo Basement: ❑Yes o Basement Plumbing: ❑Yes ANo IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: ❑Conventional ;,Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑New Well ❑Existing Well ❑Community Well Do you anticipate additions or expansions of the facility this system is intended to serve?0 Yes I(0 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 knowledge. 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 laXcaj d Hiles. I understand that I am responsible for the proper identification and labeling of property lines and comers and oand flaggi gibing the yiouse/facility location,proposed well location and the location of any other amenities. X Site Revisit Charge Property owner's or owner's legal representative signature Date(s): 3 Client Notification Date: Date EHS: Sign given ❑Yes❑No Account# , D Revised 11/06 Invoice# �t Davie County,NC Tax Parcel Report Friday,March 18,2016 j 4112 i N w 555 j 157 287 110 EO N _'' 2 3 n nj N "' a`4118 co0)76N L - M 2165 i 1212 l % f I l � TRACT 1 lAft WARNING:THIS IS NOT A SURVEY r � x _o n.;,.z,.�_p,w MParoeiIriform2tion Parcel Number: G400000063 Township: Mocksville NCPIN Number: 5830044118 Municipality: Account Number: 82531717 Census Tract: 37059-806 Listed Owner 1: COPE LARRY G Voting Precinct: CLARKSVILLE Mailing Address 1: PO BOX 1160 Planning Jurisdiction: Davie County City: COOLEEMEE Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overlay: Zip Code: 27014-0000 Voluntary Ag.District: No Legal Description: LOT 4 CANA ACRES Fire Response District: WILLIAM R.DAVIE Assessed Acreage: 1.06 Elementary School Zone: WILLIAM R DAVIE Deed Date: 9/2012 Middle School Zone: NORTH DAVIE Deed Book f Page: 009010507 Soil Types: GnB2 Plat Book: 0009 Flood Zone: X Plat Page: 062 Watershed Overlay: - Building Value: 0.00 Outbuilding&Extra 0.00 Freatures Value: Land Value: 27500.00 Total Market Value: 27500.00 Total Assessed Value: 27500.00 v*ire All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the Davie County,NC implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of Davie,North Carolina,its agents,consultants,contractors or employees from any and all claims or n causes of action due to or arising out of the use or inability to use the GIS data provided by this website. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION 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% HORIZON I DEPTH O-- Y Texture groupc-- 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 5 LONG-TERM ACCEPTANCE RATE 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 CONSISTENCF Moist 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 Mineralogy 1:1,2:1,Mixed 1�s 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- eal/dav/ft2 r1run ncmc -- DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751=8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 989900283 Tax PIN/EH#: 5830-04-2225.04 Billed To: Bob Cope&Son Construction Subdivision Info: Can`a Acres Lot#4 Reference Name: Location/Address: Cana Road-27028 Proposed Facility: Residence Property Size: 1.01 ac. .r= . Y ATC Number: 4802 / 8 Site Type:X1ew a ❑Re air ❑Ex nion YP P P **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.1 00 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FO PERIODrOF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications:.,.#Bedrooms ✓ _#BathroomE-�'5 #People Basemen asement plumbing❑ Non-Residential Specifications�'Facilit`Type #People #Seats Square,;Footage(or Dimensions of Facility) Lot Size A:C Type of Water Supply: eCounty/City ❑Well ❑Community Well System Spefic'ations: Jesign Wastewater Flow(GPD) SizeAL.Pump Tank GAL. Trench Widtha&..o Max.Trench Depth Rock Depth Linear Ft.--51-�>O Site Modification/ onditions/O er: - r Contact the Davie County Environmental Health Section for final inspection of this system between 8:30—9:30a.m.on the day of installation. Te hone#(336)751-8Z60. IQ 1 1414,110 3z's. Environmental Health Specialist Date: Ctg DCHD 11106(Revised) i DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760 Fax#(336)751-8786 OPERATION PERMIT Account #: 989900283 Tax PIN/EH #: 5830-04-2225.04 Billed.To: Bob Cope&Son Construction Subdivision Info: Cana Acres Lot#4 Reference Name: Location/Address: Cana Road-27028 ' Proposed Facility: Residence Property Size: 1.01 ac. ATC Number: 4802 **NOTE**The issuance 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) 5�'39' E tyS4.d3 to�Qt) M80 110.36 � w■ 1 42�0 f --Lar. LOT 8 REA-wi.010 AC. . } } 'F s nbny 0400* t . /. 17. 0 ' m t I3 `� OOOOPA oo OOP 43 1 �' APPLICATION FOR SITE EVALUATION/IMPROVEME Davie County Environmental Health P.O.Box 848/210 Hospital Street DFC 30 2407 Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 fNVzpANMEMgt N Application For: E) Site Evaluation/Improvement Permit .Authorization To Construct( TC) 11YY Type of Application: fdNew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed �`Y'� a Contact Person ��n"'/ e Billing Address PO, & !t Home Phone qa 50 S' City/State/ZIP &94 Ce lg ee Business Phone Name on Permit/ATC 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) (Permit is v�llid.for 60 months with site plan,no expiration with complete plat.) Owner's Name /�dah Phone Number C�DQ--U y� Owner's Address 50fyC_. 44-YX,<- City/State/Zip Property Address City Lot Size /P /X /,sem- e- Tax PIN# Subdivision Name(if applicable) Ci,A�t Section/Lot# `l Directions To Site: 0,7a t^� 6 h 4Jcy.4;,,,rci If the answer to any of the following questions is"yes",supporting documentation must be attached. Are there any existing wastewater systems on the site? ❑Yes P?lo Does the site contain jurisdictional wetlands? []Yes EWo Are there any easements or right-of-ways on the site? ❑Yes ❑No Is the site subject to approval by another public agency? ❑Yes Ii Vo Will wastewater other than domestic sewage be generated? ❑Yes [Hqo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms i-- #Bathrooms % Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbing: ❑Yes �No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested:. ❑Conventional ❑Accepted ❑Innovative ❑Altemative ❑Other alp ,-�f.-A'. l;;;K Water Supply Type: U County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes J?Ko If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permits)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 understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or stak'ng the house/facility location,proposed well location and the location of any other amenities. t Site Revisit Charge Prope owner's or wner's legal representative signature - Date(s): D Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# g7,f-7 t./F Revised 11/06 Invoice# 0 f . Davie County Environmental Health P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-8760/Fax(336)751-8786 IMPROVEMENT PERMIT Account #: 990002706 Tax PIN/EH#: 5830-04-2225.04 Billed To: Jeff.Hayes Subdivision Info: Cana Acres Lot#04 Address: 130 Hwy 801 S Location/Address: Cana Road-27028 . City: Advance property Size: 1.01 Acres Reference Name: Proposed Facility: Residence **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'ssubject`to 4 revocation if site plans,plat or the intended use change. Permit Type: Zf& ❑Repair []Expansion Permit Valid for: 05 Yeais;erNo Expiration Residential Specifications: #Bedrooms #Bathrooms �—?w #People Basement❑Basement plumbing❑ Non-Residential Specifications: Facility Type '. 't#People #Seats Square Footage or Dimensions of Facility) Design Flow(GPD):�C� � Type of Water S ppI : C}funty/City ❑Well ❑Community Well Site Modifications/Permit Conditions: I System e LTAR ' Initials j spa f` Repair r' } - 0 Site Plan Environmental Health Specialist Date i.p.11-06 I W I I , V �� I ! 3 W •(v Q I v N O (_r rr.� • �t V O - J 11 2 "= N 87.52'39' E (554,65 total) .0 ' % 287.49 t 110.36 156,@0 -p rn �o m`� I r u� 3) / 4,, / �e �~ / ON® a LOT 2 I LOT .3 I jW 1 j LOT 4 N 7) A / AREA=2.009 ACRES AREA=1.010 AC AREA=1.010 ACRES D' (D.M.D.) I (D.M.D.) Iv�Oi ,oI I (D.M.D.) I 8) N, ® 14�iP 22.Zp p7 r E / O C• I I I 1 115' UTILIITY J e EASEMENT ® �'�•\ jI I � I � I �I • S 55.52'59• W /' 17.50 13' • o�`�� �� �61;41 8S �. � I J I I e52�` per w ���' � \51 �✓ �•\ / ; _ �,�'� I I 563 /,� .gas •\ / .�'� I I 5a w / r / OLA C. BOGER v ��;h2 Lp o�21, w PL.BK. 9, 1' 27 s s 6c) 15' UTILIITY 19 PPVE� // REF.: D.B. ss, PG. S84 EASEMENT 'X -'IAP: G-4, . ' ZONED R- PARCEL 12 �•® '99P �� ' .�� 407 4 � •�' R e TUTTEI on APPLICATION FOR SITE EVALUATIONAMPROVEM Davie County Health Department Environmental Health Section SEP C 20,06 P.O. Box 848/210 Hospital Street Mocksville,NC 27028 ENVIROM&ENTAL HEALTH (336)751-8760/Fax (336)751-8786 DAVIE COUN Application For: rte va uatto mprovement Permit 0 Authorization To Construct(ATC) ❑ Both ***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed Contact Person Billing Address -J Home Phone Dlw� City/State/ZIP / ,u� iness Phone Name on Permit/ATC if Different than Above /vv Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for 60 months with site plan,no expiration with complete plat.) � � LS Street Address City Tax PIN# 7 70Z- Subdivision Name' S ction/Lot# Lot Size Directions To Sit Date House/Facility Corners.Flagged ' If the answer to any of the following questions is"yes",suppo ing d cumentation must be attached. Are there,any existing wastewater systems on the site? ❑Yes Quo Does the site contain jurisdictional wetlands? ❑Yes 5No Are there any easements or right-of-ways on the site? 9yes ❑No- W Gl--� Is the site subject to approval by another public agency? ❑Yes Flo Will wastewater.other than domestic sewage be generated? ❑Yes lkgo IF RESIDENCE FILL OUT THE BOX BE #People #Bedrooms #Bathrooms _ Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbi g: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) . FOODSERVICE ONLY: #Seats Type system requested: onventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type: County/City Water ❑New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes N�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 knowledge. 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 infonmation submitted in this application is falsified or changed. 1 understand that I am responsible for all charges incurred fi•onz this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to detertflnce with pli ble laws ap{l�les on the above described property located in Davie County and owned by Site Revisit Charge Property o� ier°s oro is legal re sentative signature G� Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account# Revised 2/06 Invoice# APPLICATION FOR SITE EVALUATIONAMPROVEM D ( u L Davie County Health Department k . ' Environmental Health Section SEP 6 2006 P.O. Box 848/210 Hospital Street Mocksville,NC 27028 ENVIRONMUITAL HEALTH (336)751-8760/Fax(336)751-8786 DAVIE COU( Application or: ite va uatio improvement Permit ❑ Authorization To Construct(ATC) ❑ Both ***IMPORTANP***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed .J-e Contact Person �LF Billing Address XO I Home Phone City/State/ZIP Bu'ness Phone Name on Permit/ATC if Different than Above /D Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A surveyplat or site plan must accompany this application. (Permit is valid for 60 months with site plan,no expiration with complete plat.) Street Address �CityTax PIN# 07L1 22 Subdivision Name S ction/Lot# Lot Size Directions To Sit Date House/Facility Corners„Flagged If the answer to any of the following questions is"yes",supporfing d cumentation must be attached. Are there any existing wastewater systems on the site? Dyes f (o Does the site contain jurisdictional wetlands? Dyes t�,No (� _ Are there any easements or right-of-ways on the site? gXes ❑No—� W C�- 'l Is the site subject to approval by another public agency? Dyes Flo �- Will wastewater.other than domestic sewage be generated? Dyes 1�90 IF RESIDENCE FILL OUT THE BOX BE #People #Bedrooms #Bathrooms _ Garden Tub/Whirlpool ❑Yes ❑No Basement: ❑Yes ❑No Basement Plumbi g: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested:Xconventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply Type County/City Water ❑ New Well ❑Existing Well ❑ Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 1�uqo If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. 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 understand that I am responsible for all charges incurred from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to dete n gli ce with pli ble laws apo rules on the above described property located in Davie County and owned by �C� i`7 -- " Site Revisit Charge Property owner or o is legal re sentative signature Date(s): Client Notification Date: Date EHS: Sign given Dyes ❑No Account# Revised 2/06 Invoice# y pAr° 1 S1\fir .r�Na� i7-.� W.ur ��a�,'\\ eL.� � � �r�°` e'• rn" ��^��`�'� -.>�� �,;s'� a t;V Fro' .c .,fi r f y7 t`r i w�r. .1 ,M1•u Yt 4t R+-`t H a '"r 1q ry ��}...4t �- . , > s.. a � -ivy}''e;,•±� _---� WX iv j�vyp���.•`� s��, � eF� '""`4 k ..•!r' rr, � y/�T j�3y. � 7 "fi'}� ! ti -■ � z� V y i e •Y.fi• f ' �` R k Yeo:-.. t[1C t !f'�h irk. i .r� � r a r le I ,_,+{. .roe '• ) : S� ' 4n.,r)y r N 'I 1 , IWT 1 • / j I � % t f v My 1 �':�,` \ - / ;/ �`\•..� J '�/ r i 1 s• %r � i roar S 514.99 AXSj'11, E lE ro AXLE) 159.03 130.84 7 AkLE _ 35.37 7T 2 / / I 0.6'91 AC. SQ. FT. LOT 3 AREA=0. 778 AC. 33,895 SQ. FT.,, / LOT 4 / /AREA=0. 786 AC. \ \ / / / / 34, ./226 SQ. FT. /. / ,e \ 1 7 Vk'J 7� / I •• X A_39 3 . 1 R k n i 4 cs \ LOT 5 I Q , II OREA=0.691 ACl p "� q0, 100 SQ. FT.[ In y~ \ n 1 i 1 I Vf1r P 4 /z C.l v LOT 6 l /! AREA=0.691 AC. I LOT 7 I ! i 30, 106 SQ. FT. /. REA=0.818 AC.1 1 135,648 648 S Q. FT. I IIII l � In I J I ^ N o / . Vol. %b IRON A qp ao p2 V JNA. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002706 Tax PIN/EH#: 5830-04-2225.05 Billed To: Jeff Hayes Subdivision Info: Jeff Hayes Lot#05 Reference Name: Location/Address: Cana Road 2702 Proposed Facility: Residence Property Size: 0.691 ac Date Evaluated: L7 alo Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit ✓ Cut_ _ FACTORS 21 22 3$ 4 5 6 7 Landscape position Slope% HORIZON I DEPTH _ - 1 Texture group Consistence S Structure CX L Mineralogy ` HORIZON II DEPTH r HC i Texture group C_ Consistence Structure Mineralogy a HORIZON III DEPTH Texture group Consistence Structure MineralogyI x� HORIZON IV DEPTH 3 Texture group Consistence Structure Mineralogy SOIL WETNESS HU RESTRICTIVE HORIZON qC SAPROLITE CLASSIFICATION r LONG-TERM ACCEPTANCE RATE Z SITE CLASSIFICATION: PS EVALUATION BY: �Y LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: i.an a gee Position LEGEND 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 Sl-Silt SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTFN[F HQLq VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm 3Yet 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 Sam 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 05105(Revised) ( APPLICATION FOR SITE EVALUATION/IMPROVEM 1�p U LDavie County Health Department Environmental Health Section SEP - 6 2006 D P.O. Box 848/210 Hospital Street Mocksville,NC 27028 ENVIRONMENTAL HEALTH (336)751-8760/Fax (336)751-8786 DAVIE COUP Application or: 1-te-E­vaTu—atRon7rmprovement Permit 0 Authorization To Construct(ATC) 0 Both ***IMPORTAN9`***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATTIOON Name to be Billed J e-l-� Contact Person Billing Address ✓ Home Phone City/State/ZIP $u�iness Phone Name on Permit/ATC if Different than Above D(� Mailing Address City/State/Zip PROPERTY INFORMATION NOTE: A survey plat or site plan must accompany this application. (Permit is valid for 60 months with site plan,no expiration with complete plat.) Street Address City Tax PIN# � 22- Subdivision Name S ction/Lot# Lot Size Directions To Sit Date House/Facility Comers.•Flagged If the answer to any of the following questions is"yes",suppo ' g d cumentation must be attached. Are there any existing wastewater systems on the site? 0 Yes Edo Does the site contain jurisdictional wetlands? ❑Yes "o Are there any easements or right-of-ways on the site? gYes ONo— W Cci�cp-( Is the site subject to approval by another public agency? ❑Yes filo Will wastewater.othet than domestic sewage be generated? Oyes EWo IF RESIDENCE FILL OUT THE BOX BE #People #Bedrooms #Bathrooms _ Garden Tub/Whirlpool ❑Yes ONo Basement: OYes ONo Basement Plumbi g: ❑Yes ❑No IF NON-RESIDENCE FILL OUT THE BOX BELOW Type of Facility/)business Total Square Footage of Building #People #Sinks #Commodes #Showers #Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: #Seats Type system requested: Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other Water Supply TypetCounty/City Water 0 New Well ❑Existing Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? 0 YesIo If yes,what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. 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 understand that I am responsible for all charges incurred fi-om this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to detc of om, ce with pli gble laws W rules on the above described property located in Davie County and owned by �flJ� jj} . /,C.1L �y6(��� Property o er's oro is legal re sentative signature Site Revisit Charge Client Notification Dale: Date EHS: Sign given ❑Yes []No Account# x706 Revised 2/06 Invoice# - J � T � s. s t''r .n:,�?C1 ', !7�+�hF4 +.+� ¢ y y� ._, l✓ ,Sk�i r�' � t i.. � e " � F• �� ,� Yt •C WWI4! ,.a �'^�- ••� c ,jis . • .,:iPs�arx r.' .Xe s erio-�r�� `��- :r::.. — 3,Vow ;. -77- ti C l 1 _ � � N it ■ r _. _ � Wl f 1' L Y ` h e>i tii y 7 / / J / k q� I �j T / yM� 11 r� 1 t � • Ij�'u ,n,� . � � �� " �sr it a� I � f f b l ( + 1 Al fi h n k ter 4 Lo 02 io C-) 171.32 S 01'25'31' V V9 4Z, COO .C* Q C14 C) 1p t C/) ay JF� 2 OQz 1p 106.47 C', 323 89 55e.-24 • . DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990002706 Tax PIN/EH#: 5830-04-2225.06 Billed To: Jeff Hayes Subdivision Info: Jeff Hayes Lot#06 Reference Name: Location/Address: Cana Road-27028 Proposed Facility: Residence Property Size: 0.691 Date Evaluated: 61127 Water Supply: On-Site Well Community Public ` Evaluation By: Auger Boring Pit Cut FACTORS @I$ 37 3 4 5 6 7 Landscape position L Sloe% 7d L16 20 Co 2v HORIZON I DEPTH b—23 0 ' IC) Texture group 01 Consistence Structure SIC- Mineralogy v Mineralo ,: HORIZON H DEPTH 10_�-( Q — r Texture group G 5, G•1 C 4 S,e Consistence Structure Ask MineralogyL HORIZON III DEPTH Texture group Consistence Structure Mineralogy - , HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS 35 d RESTRICTIVE HORIZON 2-3 T SAPROLITE ?- CLASSIFICATION LONG-TERM ACCEPTANCE RATE `, ©•/2 a SITE CLASSIFICATION: l�� EVALUATION BY. �% 1-�&-1'Sl�CAA--,V LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT: REMARKS: . �`��� ��o �t7 ,,4 � 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 41St _ CONSISTENCE 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 Mineralogy 1:1,2:1,Mixed 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 05105(Revised)