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198 Falling Creek Drive Lot 17Davie County, NC ITax Parcel Report Wednesday, December 21, 2016 WAKN114G: TMN IN 140T A SURVEY Parcel Information Parcel Number: 9bt� H9080A0017 Township: Shady Grove NCPIN Number: 5789634740 Municipality: Account Number: 82524152 Census Tract: 37059-804 Listed Owner 1: KANE RONALD A Voting Precinct: EAST SHADY GROVE Mailing Address 1: 198 FALLINGCREEK DRIVE Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27006-0000 Voluntary Ag. District: No Legal Description: LOT 17 FALLINGCREEK FARM PHASE 11 Fire Response District: ADVANCE Assessed Acreage: 0.79 Elementary School Zone: SHADY GROVE Deed Date: 1/2011 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 008480274 Soil Types: PcB2,PcC2 Plat Book: 0007 Flood Zone: Plat Page: 189 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding & Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: All data is provided as is without warranty or guarantee of any Idnd 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 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 causes of action due to �O ti ty S NC or arising out of the use or Inability to use the GIS data provided by this website. Permittee's " AVIE COUNTY HEALTH DEPARTMENT_ - Name:i Environmental Health Section PROPERTY INFORMATION M _ P.O. Box 848 ,, ' t Directions to property:"='. �' " Mocksville, NC 27028 Subdivision Name:'[ . ` Phone #: 336-751-8760' s Section Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# �SYSTEM- - CONSTRUCTION � 2441 AUTHORIZATION NO: A Road Name: i t.Lt{-: Zip:X **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,l 1 of G.S. Chapter 130A -,.,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) j ' r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 04 IS VALID FOR A PERIOD OF FIVE YEARS. t+. ENVIRO A ESP CIAL[ST�r DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE# BEDROOMS # BATHS #OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS' INDUSTRIAL WASTE: Yes or No LOT SIZE22)4PE WATER SUPPLY l � DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE' C GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 2 Y' LINEAR FTs OTHER �'�-►Sktlt�a �� REQUIRED SITE MODIFICATIONS/CONDITIONS: �`L � �� ) 5t Tom / ��SP O� G (a. "*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 02/02 (Revised) rl '.;, �: DAVIE COUNTY HEALTH DEPARTMENT t. VI _.. "'� Environmental Health Section PROPERTY INFORMATION P.O. Box 848 P.... Directions to property i �r� t 1 .`.1 :f;- Mocksville, NC 27028 Subdivision Name: _!-•t.' + _:...k. i .t,, • ' ,�-r., .. a Phone #: 336-751-8760..' Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# ' SYSTEM CONSTRUCTION ¢ -, , 2441. 1� � ` i �•ut '�� `zip L AUTHORIZATION NO: A Road Name i , **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior to issuance Iof any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pen -nits. (In compliance with Article I ].of G.S. Chapter 130A; Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) t 4 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION Lit`y ,IS VALID FOR A PERIOD OF FIVE YEARS. -ENVIR MEN ,AL,4ALTH SPECIALIST DATE'ISSUED J � RESIDENTIAL SPECIFICATION: BUILDING TYPE M&# BEDROOMS # BATHS # OCCUPANTS "- GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATSINDUSTRIAL WASTE: Yes or No LOT SIZE ti^`�PE WATER SUPPLY 6''' ,DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH i LINEAR FT.,--&-•L•� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: 11-Yr,�,�. t\LL GIA, .Yrwk 1 4A t 5 C'S -T T { L / I_ L'" l L" } C,f I IMPROVEMENT PERMIT LAYOUT ���^ L/'1 ���'t.:• i.:.�'7 tw �,,,lkjM.�,�4 � �.� �>i.� t ( Y� M1 4� f� - .,.� �� .�"` `moi Ilk AD "CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 = 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO. OPERATION PERMIT BY: DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1960 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILYTOR ANY GIVEN PERIOD OF TIME. Henn 02/M (Revised) n d�/ ll J (�E�-.3 `7 ' DAVIE COUNTY HEALTH DEPARTMENT / Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 ATC Numcei: 3050 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 WASTEW CO ON VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur : Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. I- t� ,t16 el r f 1110 lo�7 xlZ ,► 'J a�1L bArtC 2-0 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) �)fto. S" 107-0 501L., Flu- 7ti-r .� 5C AP f -ilex- Two L t Vt�,) g&AZ -L2,L�,, VVI e� L- to-) 1 ACCuunt m: 990002128 Tax P11NUEH ,r. 5789-63-4740 BiiiCd To: Phase IVRealty Falling Creek one Lot # 17 Reiefenc;e igaftie. Loc ativiii'r:.'• 198 Falling Creek Drive -27006 Proposed Facility: Residence PropeiTy Size: .821 acres ATC Numcei: 3050 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 WASTEW CO ON VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signatur : Date: CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. I- t� ,t16 el r f 1110 lo�7 xlZ ,► 'J a�1L bArtC 2-0 Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) �)fto. S" 107-0 501L., Flu- 7ti-r .� 5C AP f -ilex- Two L t Vt�,) g&AZ -L2,L�,, VVI e� L- to-) ` �. ���� to m°�" '" �-� � yE§� • ,Ih�i r RI» w f � S � / s,%vim " r✓ R x r t t e sad a "ra � d v i3H ,* DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section _ _ 6 1— P. O. Boz 848/210 Hospital Street`t Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990002128 Tax. PiNIEH m_ 5789-63-4740 Billed To: Phase IV Realty Sv.:Aivislon In.o: Falling Creek one Lot # 17 Re{4i��. nw Na :ke: LocationfAdd.ess: 198 Falling Creek Drive -27006 Proposed Facility: Residence Property Size: .821 acres ATC Number: 3050 **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 Nom #People #Bedrooms 3 #Baths 2. Dishwasher: G!r Garbage Disposal: u Washing Machine: E Basement w/Plumbing: d Basement/No Plumbing: ❑ Commercial Specification: Facility Type 13^ _ #People #People/Shift #Seats Industrial Waste: Lot Size ©.$2 A0-� Type Water Supply W Design Wastewater Flow (GPD) --ice Site: New Repair ❑ ��� 1 System Specifications: Tank Size/000 GAL. Pump Tank GAL. Trench Width 6& � � Rock Depth � Linear Ft. Other: 3 to 3 -ROxGS , i TAU— U t3rj (Oil O.C. f,^4 I-Ij . r Required Site Modifications/Conditions: I NS -LL O -j (`0,3TOLY, IS 0 c 1`a; r I O GFF � IMPROVEMENT/OPERATION PERMIT LA FINISHED GRADE. **** OTlntact a system between 8:30 a.m. to 9:30 a.m. or 1:00 p.n W �G Environmental Health Specialists S`a Y.9 -APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW presentative of the Davie County Health Depaent for final inspection of this to 130 p.m. on the day of installation. Teleph ne # is (336)751-8760.**** 0 DCHD 05/99 (Revised) 2,,q_-- 1 Date: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account me 990002128 lax Pl ui=1-t 1 5789-63-4740 Billie~: i u: Phase IVRealty Ducriivisitou into: Falling Creek one Lot # 17 Rek;fence Narsic: LocailoniAcickcss: 198 Falling Creek Drive -27006 Proposed Facility: Residence Property Size: .821 acres ATO Numi)er: 3050 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 WASTECOON VALID FOR A PERIOD OF FIVE YEARS. fpzyEnvironmental Health Specialist's Signatur : Date: 3o I 0 CERTIFICATE OF COMPLETION **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. C r I to /pp f 0 /L �G" xl z , bA-fC 2 - I Septic System Installed By: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) 6�LLq J -OE 1,3Ta ox -1-0 L.- FILL- - FIU-- "D19-1 J SAP Ukt — Demoul taj o� rtib tW,) av-t VV... e�� W# ....,.� sivauIIl1YLM LA11 r1:11M11 1111 All; Davie County Health Department ' Envimamenta/MARIO SwHon P.O. Box 048/210 Hospital street Mocksville, NC 27028 1336) 781-8760 JAN25 ENVIRONMENTAL HEALTH hAVIE rnntimr •e4I!lPCII2T�lIr'l+�*• THIS APPLICATION Cannot IN FFA SMM UNLESS ALL THE REQUIRED INI DRMATION IS PROVIDED. Refer .to the 101=0=I08 BULLETIN for instructions. Naxw to be Billed 7 /7 9-11 Contact parson A I 1 �094� Hailing Address ui k zew 2DiIN SioNd phonea-- city/state/LIP W -,o t mom , ly.G r %167Business Vhww Naos on Perdt/ATC if Different than Above flailing Address ]Application, wort t .,OSite . =valuation systam to semice: P/'Housa 17 Uobile Home if Residence • 9 10 s asber City/state/Zip Improvement Permit/ATC 0 Both 0 Business 0 Industry 0 Other i Bedrooms '3 ""22 age Disposal �asbinq Naahim i. if Business/Indastsy/other: specify type i Cawood" '_ �asemeat/Plaabing i Bathrooms .C9 O Basement/110 Plumbing i People i Bina& i showers i urinals i Mater Coolers IP., ToADS1I:Ri1itz: # Seats Ratimated Water Usage (gallons per day) 7. Type of water anpply: Ercannty/City 0 Well 0 Coesmnity s. Do you anticipate additions or espansioos of the facility this system Is Intended to nerve! 0 Yes �io U yes, what type! "*'IMPD�TAIQT"" CLIEI+ tsAtusicphinE1Ente-AEQUIREDPROPERTY INFORMATION REQUESTED BELOW.'• Silber s PLAT or S1119 PLAN MUStZWSUBUITTED by the client with THIS APPLICATION. Property Dimensions: AopeyS WRITE DIREC11ONS (from Mock:ville) to PROPERTY: TasrOtlki���• ••.# j •75^J- �3��7s�a ® � O1(J Property Address: (toad Name � t� � }' 4"o V City/Zip Ady14 gl �, &, W ��& 1Y P%PrA If in a Subdivision provide information, as follows: Name: Section: Block: Lot: % Date Property Flagged: This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) Issued berealter are subject to suspension or revocation, if the site plans or intended use cbauge, or If the inrormation submitted In this application is raldtkd or changed I, alto, understand that I am re:yaonale for all charga Lrcorrrd fi om this gpp/lca"L I, hereby, give consent to the Authorized Representative of the D vieounty Health epart tent to enter upon above described property located in Davie County and owned by a "p s to conduct all testing //procedures as necessary to determine the site�a% bility. 4"g DATE o 7 — � L SIGNATURE 1 s L� THIS AREA MAY BE USED FOR DING YOUR SITE PLAN (include all of the following: Z*Wg and proposed property lion and dimensions, 5mCluiek setbacks, and septic locations). 0 Revised DCHD (07!98) s� c� 7)3+2 Account No. Invoke No. Y� M►tlfOR O/ AKMPIlt PIAAN/NC OLTARTMLRf/R!V/!1 0!I/CLR • /IRAL lUNDIVIJlOR PLAT APPROVAL SURVIYOR! 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Mr.�lvr __� _._� f \ � P P w • • n. r r• r .• IINC TAB_LC LINE TABLC o I"•^^'-T-�'---C`- ^r I. •' -Ir lCWlw _L LIW1N ^fCARING LNI wwt� Ir••�• Ir•.•,... ••-1F1�-% / lIM" r ftAR.W LINE TABLE _LIN[ LIf( •• p.,y C^,w-ew er ^e•�`v rt•.e -. �7-- . rr.« � L1 I.r� �� w•.w� ._ KAflrry f n:.r..`_-..j �.. o...-___��..r-.�... • o r. e 4444•. •.•1••r... r...... _--t -T� a.•» f -!1 : r '1 ' ! I 'qr °. - - e - ` 01!77 C-f7ry„P_r« a .43 id _-Y__.i!! __u � 7 _ _..it 1 � lirx • .. •..r • 1 .r.• !' »►r o�e _ r, .. -' ___ .!L � _ e.... a � � Ili .. � _ � � � t v e .. �x 7L.•S -- -- i!.. -.•iri - --- ' 1 car •'n• I r 4444 ... •i rni.{ - ili3y li---__t3 n' �i•rx j �..�-___ .. w1 ii _. f li r. iil t u• Ni, 4444 ._ - I• 1 i1'�aiel ._. ;�i _ 11a )i iit -,;.- '. �: x°1 i - flEEJt10 EnnineEnInil IpC- ._ APPLICATION FOR SITE EVALUATION/ M IMPROVEMENT PERMIT & ATC! ; Davie County Health Department JAN 2 4 2000 Environmental Health SaWon P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ENVIRONI (ENTAL HEALTH (336) 751-8760 DAVIE COUNTY ***nWCRTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed �8MJ'k�,.)bKt14LaoMC�t.1T (_()MftW Contact Person &ANT 6dormy Mailing Address U31 2EynlotoA RaAD Home Phone R34-760- 2408 City/State/ZIP Wi11tTCM LEWI. )dc Business Phone 3U-111-013%$ 2. Name on Permit/ATC If Different than Above Mailing Address / 3. Application For: ff Site Evaluation City/State/Zip Improvement Permit/ATC ❑ Both 4. System to Service: eHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms 3 # Bathrooms 11 Dishwasher 11 Garbage Disposal t] washing Machine f] Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/industry/Other: Specify type # People # Sinks # Commodes # showers # Urinals # Water Coolers IF FOODSERVICE: # Seats// Estimated Water Usage (gallons per day) 7. Type of water supply: B'County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes El No If yes, what type? ***IMPORTANT*** CLIENTS MUSTCOMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION. Property Dimensions: Tax Office PIN: # 5789 - 6q -14 8?—+ 67 Property Address: Road Name FALUfJ44A f,-NlvG City/Zip A Olrwa . Nt VIA cad If in a Subdivision provide information, as follows: Name: FAwN6tUe< 7f7tAcrs /7 Section: Block: Lot: corf 17 t 3 X1-41 WRITE DIRECTIONS (from Mocksville) to PROPERTY: Date Property Flagged: /1-71-51 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 the Davie County Health Department to enter upon above described property located in Davie County and owned by JA/CTJ*VW- J L-66 H.0/M6r►1 g:=Q 'N)1 to conduct all testi/ng procedures as necessary to determine the site suitability. DATE l 3 /Oa SIGNATURE THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all oft o owing: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). SFW MAP wT 17 Revised DCHD (07/99) Site Revisit Charge Date(s): Client Notification Date: I EHS: Account No. &� Invoice No. �� If Foodservice: # Seats Estimated Water Usage (gallons per day) i 7. Type of water supply: ❑ County/City ;' ❑ Well ❑ Community 8. Du you anticipate additions or expansions of the facility this system is intended to serve? El Yes ; E3 No a , :# L. yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST aE SUBMITTED WITH THIS APPLIC/i ` 1N. Property Dimensions: 7 q, ( 74 IlZre—S 1 WRITE DIRECTIONS (from - Mocksville) TO PROPERTY: Tax Office PIN: # 63 - 7 D 3 ; Property Address: Road Name -F-4 p -a/ 5Lezk. ZsL • 1 // ` JI City/Zip AdyaiVd 4:: rr If in Subdivision de tion, as follows: - �/ „j 1 Name: Section: Lot # 1 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 ,g :i 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 the Davie County Health Department to enter upon above described property located in Davie County and,c. wined by 1pa to conduct all testing procedures ' as ne. essary to determine the site suitability. 3 DATE— cl SIGNATURE :... a Revi-?d DCHD (06-96) �C ��1 . r _ APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMITIE E — Davie County Health Department a v D a Environmental Health Section .t P o. Box 848 AUG — 61997 • Mocksville, NC 27028 (704)634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE ALL THE REQUIRED INFORMATION IS PROVIDED. // �ey�on� �n. G 1. R':me to be Billed WO-s� /c uJ Contact PersonV I4 :ailing Address STS SraA Sb, b � r' ra u/ Home Phone City/State/Zip L ,vs iN a/ 56k, Abe, Q 712 3 Business Phone 9 9g, ! 2. 1.::me on Permit/ATC if Different than Above 5,4m8— oom.8Mailing MailingAddress City/State/Zip 3. Application For: 0' Site Evaluation ❑ Improvement Permit & ATC ❑ Both 4. System to Serve: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other +, 5. ,1 If Residence: #People # Bedrooms # Bathrooms ❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing ' 6. If Business/Other: Specify type y^ # People # Sinks # Commodes # Showers ''' # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) i 7. Type of water supply: ❑ County/City ;' ❑ Well ❑ Community 8. Du you anticipate additions or expansions of the facility this system is intended to serve? El Yes ; E3 No a , :# L. yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST aE SUBMITTED WITH THIS APPLIC/i ` 1N. Property Dimensions: 7 q, ( 74 IlZre—S 1 WRITE DIRECTIONS (from - Mocksville) TO PROPERTY: Tax Office PIN: # 63 - 7 D 3 ; Property Address: Road Name -F-4 p -a/ 5Lezk. ZsL • 1 // ` JI City/Zip AdyaiVd 4:: rr If in Subdivision de tion, as follows: - �/ „j 1 Name: Section: Lot # 1 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 ,g :i 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 the Davie County Health Department to enter upon above described property located in Davie County and,c. wined by 1pa to conduct all testing procedures ' as ne. essary to determine the site suitability. 3 DATE— cl SIGNATURE :... a Revi-?d DCHD (06-96) �C ��1 DAVIE COUNTY HEALTH DEPARTMENT 17 Environmental Health Section SECTION _ LOT Soil/Site Evaluation APPLICANT'S NAME DATE EVALUATED PROPOSED FACILITY _PROPERTY SIZE SUBDIVISION e /-C ROAD NAME Water Supply: Evaluation By: On -Site Well Community Auger Boring Pit L� Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position J,L Slope % HORIZON I DEPTH Texture group Consistence Structure Fyt� Mineralogy HORIZON II DEPTH i p �+ Texture group Consistence r - Structure S' l 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 SITE CLASSIFICATION: 9 LONG-TERM ACCEPTANCE RATE: n A n REMARKS: DCHD (01-90) I– EVALUATION BY: OTHER(S) PRESENT: 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 i 140B14 \ 'Cc pie c Rem Zd ConSt. °, • r 150- -6k 5p• _ \ N `v \ i 237.61' 140.43' . - 97.18' 6 \ \ �Q O I s 6 \ O u + 4 PT 1t .44 • �. \ ,�x PC . \ n R = 150 \ \ ♦ fixes. J/ n N x;gt��y Bic? s \ \ �\ Ma. 1n9 (T pL,a e T - e r'ernnved ;41,PVic se 11N.• \ 874, j, N M on5t, CTYA) so.s6- \ / •., '�` 's / 84.08' \ �Oy► �.45.70•. y I J � / �\ � I'+ � R = Cl V 113.81' QlhmOr 3 .� I 1.9.64• Y `.S,.N, uTLET STRUCTURE ti SedimP,nt Q te•2'wxI �R 0 I 76„ 4'\ � I TPA1 � •\ . • �Q� Ct:A59 "A•' S15 DNG \, \ APpROxiMATE LIMITS 125• \ t�tSTU�;E� N • 'T 467• \ \ \ • • �S I EXISTING LAKE Hoots I I 288 \ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PO..Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 /Fax: (336)751-8786 December 14, 2004 David Jackson 198 Falling Creek Drive Advance, NC 27006 Re: Septic System -Falling Creek Farms/Lot 17 Dear Mr. Jackson: At your request, I submit the following in regards to problems with your septic system. Based on observations of the site, soil conditions and water consumption records, any or all of the following may have contributed to the premature failure of the septic system(This list is not exclusive, there may be other factors): 1) The presence of fill dirt on this lot is inconsistent with the soil/site evaluations originally performed on this lot. Grading/filling and the equipment used therein may have damaged the underlying naturally -occurring soil, resulting in reduced ability to absorb water. 2) An underground spring may have emerged. 3) Some settling of soil over the drain lines has occurred which may lead to ponding of rainwater over the system. 4) Gutter drains need to be diverted away from the system. 5) Several heavy rainfall events(>3") have occurred over the past four months, contributing excess amounts of water into the septic system in addition to the effluent flow from the plumbing of the house. Taking these factors into consideration and using my best judgment, I offer the following proposals to remedy the situation: 1) Install a French drain above the existing drain field to intercept any laterally - moving, perched ground water or spring. 2) Add additional drain line to the existing system in the side yard area. A minimum of 100 linear feet, or its equivalent, would be added. 3) Disconnect upstairs plumbing from the existing septic system. Install a new septic system in the back yard to serve the upstairs alone. Minimum sizing specifications for this application would be a 1000 -gallon tank and 300 linear feet of drain line, or its equivalent. This is our recommendation. An Improvement Permit will be required to install new drain lines or to make changes to existing ones. I have enclosed a copy that includes the specifications for our recommended solution. It can be revised if needed. Further evaluation of soil conditions in the area of the proposed repair will precede any work on the system. , Please feel free to contact us with any questions, 751-8760. Sincerely, Jeff G. BeauchaitI, R.S. Environmental Health Section Enc(s)