247 Peoples Creek Road Lot 1Davie County, NC Tax Parcel Report Wednesday, December 21, 2016
141
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---- -- -- -- - -2 42 ;-- — -- - --- —
101
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 orlitness 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
NCor arising out of the use or Inability to use the GIS data provided by this website.
WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number:
H908OA0001
Township:
Shady Grove
NCPIN Number:
5789528843
Municipality:
Account Number:
82516846
Census Tract:
37059-804
Listed Owner 1:
SMITH BETTY LOU
Voting Precinct:
EAST SHADY GROVE
Mailing Address 1:
PO BOX 2045
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 1 FALLINGCREEK FARM PHASE I
Fire Response District:
ADVANCE
Assessed Acreage:
0.70
Elementary School Zone:
SHADY GROVE
Deed Date:
5/2001
Middle School Zone:
WILLIAM ELLIS
Deed Book / Page:
003690688
Soil Types:
PcB2,PcC2
Plat Book:
0007
Flood Zone:
Plat Page:
048
Watershed Overlay:
DAVIE COUNTY
Building Value:
Outbuilding & Extra
Freatures Value:
Land Value:
Total Market Value:
Total Assessed Value:
101
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 orlitness 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
NCor arising out of the use or Inability to use the GIS data provided by this website.
y�~�,:d r°N `•� � .. !'. ;. ,. '. '" i t rk 4! f � i,.{, ..- t;l .. a -._ �,.. _ }: ,. ,, ..; ., i,ta "
Permittee, s i `?� / r*► AVIE COUNTY HEALTH DEPARTMENT
N 5A�v'-i t► 1 ' Environmental Health Section PROPERTY INFORMATION
V�
`1 P.O. Box 848:
r t7"ei�t+t:t�t.l�(;:,
IAr rs'�o propert�: -' Mocksville, NC 27028 Subdivision Name:
;! ; t}t`t ' Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# -
SYSTEM CONSTRUCTION - 7—
2298
AUTHORIZATION NO: ARoad Name:r%7 TCL+' CL Zip. •��lat�'�P
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pen -nits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliancelith Articc 1'oilb.S. hapter 130A,'Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
�l
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
�NVIIFONI}(TAL�,WLT1i SPECIALIST DA ISS ED
RESIDENTIAL SPECIFICATION: BUILDING TYPE r I �V BEDROOMS # BATHS' 5# OCCUPANTS e
GARBAGE DISPOS :Yes r No
COMMERCIAL SPECIFICATION: FACILITY TY�jEy J # PEOPLE # PEOPLElSHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE �/�"TYPE WATER SUPPLY`""' " fy DESIGN WASTEWATER FLOW(GPD)
( ) NEW SITE REPAIR STI'E�
SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH Z I , "LINEAR F r. SIZE( 74)
OTHER /}
II
REQUIRED SITE MODIFICATIONS/CONDITIONS: �l .UIII% V �Ii�''1:�L-�'�' 411
IMPROVEMENTPERMI
W fA Q ATC. 141 t 1 �L eyti-i: T I .�
,,..,,... Cq LICE. 011 i1 Sr 'DotA--3
�� k1 �>e 0f' ' (,,aLs F t eST
JV 1
1
'C t t. F—)(1 S'T
Stti.P'D a.
k.Lltyt �anYt
"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 Bi(: '�t°'� ✓L�'u
0
> A500
a -tel
prI�
5Td' d�Ip
� E
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA DESCR VE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.. CHAPTER 130A, SECTION .1900 "SEWAGE TREAT NT 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 0= (Revised)
r,:
M
NORTH CAROLINA DEPARTMENT OF- TRANSPORTATION -
DIVISION OF HICHWAYS
PROPOSED SUBDIVISION ROAD CONSTRUCTION
STANDARDS CERTIFICATION
APPROVED P1 • L . J]y SCA/ �,/U/� a rut,
DISTRICT ENGINE
This ihe-a Day of SE ry 6M #3 r_- _ 19 0JZ
NORTH CAROLINA - DAVIE COUNTY
an
in
to
3
ur1
In
iso
z
151_31
NO 03'20"E
PLANNINC DEPARTMENT REVIEW OFFICER
FINAL- SUBDIVISION PLAT APPROVAL,
rMe is M cert%A that L%w plat assets the recordiwp m7mvi wants
e the Unifted Dreslopment Ordtwance Subdtwun ligutatums pw
w Lbe.ty.
f .TC .a1 n! �rj.dc.:Y.+ro.tG _ p�W OJJtoor eJ Davie Cba.+aty,
sonify that the w.ap w plat to wAlch thur sent{ftoatlon fe afftesd
nests CLL atatutor"xJbr, reasrdMy_Nef t
Approved _C4 L•. �__- G� ft+�►'ir
D6,.~ of fiewwlry/Asiser Offirr
This the 23"day of 5 f PTE^^ B£n 19 `'iv
NORTH CAROLINA -DAVIS COUNTY
nEF D.ot�FaTbt
/ tf
J a.�
� k
� ry
C
+o to 3a
C_
h 1 g
116
O to
a&0
G4p�'
1Ir _
_ 18
`'rYts•58 3-
3 -E-
134.64- C-33
Leri` JY� A C-14 C- 13
�A
SURVEYORS CERTIFICATION
L vlonn L. tleeson certify that this plat was drawn under
my rupervuion fmm an actual survey mads under my ruprrviown
(description recorded in Deed Book Page or Plat Book
-PL
L - that the rmtw of precision as calculated
u 1: 1 + = that this plat was prepared in accordance with G.Y.
47-30 as amepAed 9itruss final signan registration number
and seal thud(j ay o L D. _ 19
L-1828
X Sursmyiiir Regtrtratwnn Nurnber
NORTH CAROLINA-FORSYTH COUNTY
-e-
r John E. Beeson Registered land Surveyor, iVumbrrL-1828 certify to one
of the following as indicated by an X :-
That
That thv plat %s of a survey that creates a subdivision of land within the area
of a county or municipality that has an ordinance that regulates parcels of land.
b- That this plat is of a survey that is located to such portion of a county or
municipality that is unregulated as to an ordnance that regulates parcels of land:
c_ That this plat is of a survey of an existing parcel or parcels of land,-
_ d That this plat is of a survey of another category, such as the recombination of existing
parcels, a court-ordrrvd survey or other exception to the definitwn of a subdiviision
S. That the inJbrrnation available to this surveyor is such that I am unable to make a
determination to the best of my proJ6ssional ability as to provuwns contained in
A h d, afilave.
-� L-1828
S Registration Number
NORTH CAROLf A - FORSYTH COUNTY
certificate of Ownership and Dedk:atlm_
We the undersigned hereby certify that We are She owhere of the
property deeartbed hereon• which is Located with.' the subd1wWaw
)L i tion at Dawe Cas•tx and that We hereby 000pt this subay.Far
plan with our free Consent. aid establish minimum building Setback
lrhea, and dedicate all streets, disc• walkS, parts and ether rtes•
and easmants to public or Private use an notea
Dat02hw.er'■ S19oe ral--,
„/ `rVtwJG�dr � "T•
Date own: Stghaturs
9-18-98 a t,f- U
Dau Owner -e Signature
Wcsrw4w air *w4;wNT cam,4 JY
rn CZ
30'
31 32 1 Fl o
� � �2 9 � ``
E
11 X61 20 1 C 01 - Et 34
191 t 1
• 10- tt 70• SIGHT � �
6� 2 C7 EASEMENT, TYPICAL
/!! -r- NO' -19'05'E C `
v _r�GCR�� �Rf Vn- �- Nur•
i'��L'- W 505_1
N00.36r43'w (60� PUBLtG )
DAVIE COUNTY REGISTER OF DEEDS
PLAT RECISTRATION
Filed Jbr Registrationat .2:43 O'clock_Y
This the-21-Dayooff 5&&m Ger 19-10 and recorded
to Rat Book L -Page 40
Filing Fee Paid AcAry L S& TtS Registeern of Deeds
Depeiy- Assistant
ct� Peo :h
ea,
a
Mark an=� `
act / Se -t -
.Myers
� C^s �
Ba�iey a
027` Z ...... ` 126.00 M.4 X00OQ C-1 t.6. SqQ=_ N54 -1 -15 -LV
22
its r..
_ _ j 00 125.42` � 8� t 49.09`
Lo 3 0.704 ac_f 4 `a�
G-1 Lo 2 ` N �� In ( J P
16
C. kD
ui G 3073 3 y ZS`39; - ?`� f 9999
j. i0 Z fig. (!
3 i ' C17Q3 Ae.f - .f% '� �`, Qe
o> .. 1. - O u_692 kc -:t rn E
'r] h r-
3.:.692 Amt t.. c _ o
235.09` v cJ. cur x z v 0.692 Act SV S59%9`00`E
.r Q 820 AC_t � o crOil
o N07.32'40"E C-10 0.698 Act �1e� ��7 n ` 3 e,' a 9996'
z N p 3
0.970 Ac.t io =' i f��t7w
�i u7cc/ Q
Nnr 1 3 a 5`-r9r �..
to di 1 �o 006 to 126.38- O
Z N to t`3 37_
C-9
cur :16.26 : ti .0
s 0.723 a.c_t CV C-3 <I
t w 250-00' _ 3Q.
11
130 `� 1 Cb z SOt•2i pt E F ��
V a 3 C.693 AGt �� ,�
x'235.. -Ot'r- _ � 200.35` ,,��,, -
i j DD o� �f o / /��
1 N05'23.27"E
q6J ,5, . • �_ ` 4700 Act p ry/2
- 1 4 G� z _ i.; �g?I
z � -
- EXISTING PON - �_ °�La C-6 265 - 30
S E 2
LLS
Q L" 1 c -'r S2g D5 h o ` ., `. A_
1
0.692 Act
Pill -Z +N OS' ter < _ 1 o w �Do
= - ac
`O
252-31- �f
1 90
- ? O =
q 0 896 Ac-troc I -
/ 10 .4-18' ' 87.34`
3 261-52` ar 33.3` -
3.680 Ac = 1 to o -N..04-16'00"E N!, .�
703.79'
�- NO2'03'20"E
Parcel 45
Rcymond C_ Myers
OB 97. Pq 904
192.70` r a i S89 .4 U'+/ a
1,
896.49` TOTAL SG6Q��Z Parce: 44 42�
Cf I Rich Ord M_ Talbert certificate of Approval by P:onnrg Board
-
DB 170, F9 853 Thhr
The Dans County PtannW9 Board eby approves the
2
(J/ Record Plot for FNlmgfieek Farm lubdiv,.7hon
I QLD Z
Cj !J Date Chairman- ,runty Panning Boad
� W
160' 200' 30
R W CURVE TABLE
C L CURVE TABLE
Checked 8y-
-
RADIUS
CURVE
RADIUS
LENGTH
TANGENT
CHORD
BEARING
DELTA
C-32
300.00
134.70
68.51
F3 -31 -
.57
S14-10 52 W
25'43'35"
C-33
500.00
144.76
72-89
144.25
N07'40 55 E
16'35 16
C-34
500.00
91.32
45.79
91.19
N21-12 29 E
10'27 52
C-35
500.00
65.67
32.88
65.62
S86'13'05"E
07'31 31
k C-36
500.00'
47 62
t 23.83
47 61
S87'15'08"E
05'27 27
� W
160' 200' 30
R W CURVE TABLE
i
Checked 8y-
CURVE
RADIUS
LENGTH
CHORD
BEARING
C-1
270 00
121 23'
120 22'
S14 -10'52'W
C-2
530.00
69.61`
6956'
N86-1305 W
C-3
35.00
26.73
26.09
N75'39 49 E
C-4
55.00
62.69
59.35
S86'26 '02W
C-5
55.00
45.94'
44 62
S36 -59'03"E
C-6
55.00
30.39
30.00
NO2'46 29 E
C-7
55.00'
73.71' t
68.32'
N56'59 49"E
C-8
55.00
44.08'
42 91
S61-39 05 E
C-9
35.00
26.73
26.09
S60'34 28 E
C-10
470.00'
8.44'
8.44 1S82'5812
E
C-11
470.00'
53.29
53.26
S86'43 '58E
C-12
530.00'
38.92
38.91
S01*29'30"W
C-13
530.00'
104.88'
104.71
S09'15 52 W
C-14
530.00
9.64
9.64
515.2716 W !
C-15
530.00
95.a6
95.33
521.08 09 W
� W
160' 200' 30
Field Work By:
i
Checked 8y-
CerLfcatan of Approval. of Pr•vate (art Sewage Disposot System-
BLB
site)
Parcel:
hereby certify that the Dont Canty Health Department has evouoted the
(3)Q �f
subalmsion entitled FallingCreek Form with respect to Criteria and conditions
'ave found
tie ltaO
/
established by State or promulgated thereunder and the some is
County:
Shcdy Grove
to comply with such criteria and conditions. EXCEPT as found in such evaluation.
-
Davie
evaluation For details of this evaluation and limitations see the Witter
report on file at sold Department of Health_
/
Sheet Number
N.C_
_
Important Notice:
Job Number.
This certificate DOES NOT constitute a permit or approval of individual
Drawn By:
97214
rots in said subdivision for installation of sewage facilities -
t
81_13
ot2
BEE8011 E116111EE111(10 MC.
Date County Health Official
LOCATION MAP
NTS
NOTE
The survey to subject to any facts tkw w W M
duebnd by a fWl and accurate tats searck NOT
,hu rtuhed wu ala of this date. and +way M w.by-f w
000ewur.ts, ..yes-of-suay. +e,w,cw.» ew.wrtta
sese
record In Ofj%ce of the Reputes of DeedslCV.s
of Court. Twiw w CwvNy ria Office or srheh way
luxua bse+a w,uwed by prescript" ties
NOTES -
1 ALL dtatan.ces shown ora thts plat are horisaratat
ground distances. unless othavunss dastgnated
ZALL bearunga shown -on thir 'lar ars-basef. ave
deed or Plat bearings as noted
3 Iron stakes set at all Lot corners and '+n9k
point; unless noted otharwnSa
4 There are NO N CC S monwne is atthtn 2000
of Project
S Tota Area - 34 123 Arn. f
6 Tota Number of Lots a 33
7 Average Lot Six* - 0.915 „res r
B Existed Zoning - R -A
9 Yinunurn Building Setback Lines
Front - 40
Side 15'
Rear _ -_ - 30'
Sidi Street 25'
+0 L'hlitvs
Public water m Street
Private septic Systemic on each Lot
All utilihas all be Located underground
Pavement width - 20' (ribbon pavingi
LLGJ 'Q
ZIP Zsiattng lron- Ptpe Found w,/aase
NIP. -Novi 3/4- Iron ^Pe Set
Stc-ul td PLarated Fuld Stone Found
RZB4R._._ZsLat[+t0 Steel R&WcrnIrW Rod
found w/atse
Pt.Pont on Groused no snonun.ent
found or set
FALLINGCREEK FARM
PHASE I
OWNER/DEVELOPER
WESTVIEW DEVELOPMENT COMPANY
TAITTINCER DEVELOPMENT CORPORATION
263t REY.NOLDA ROAD
W7NSTON-SALEM_ N. C_ 27106
0' 50'
160' 200' 30
Field Work By:
i
Checked 8y-
KT/CJ
BLB
Tam Map:
Parcel:
Na_ -9
P/0 PARCEn_ 42
Township
Cltr
County:
Shcdy Grove
-----
Davie
State:
Date:
Sheet Number
N.C_
July 17.. 1998
Job Number.
Drawn By:
97214
81_13
ot2
BEE8011 E116111EE111(10 MC.
ENGINEERS
SURVEYORS PLANNERS
503 HIGH STREET
WINSrON--SALEM. NC 27101
TELEPHONE 910-748-007f
I
� _
i
- _
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account M 989900259 Tax PIN/EH #: 5789-52-8843.01
Billed To: David Mallard Subdivision Info: Falling Creek Sec.1 Lot # 1
Reference Name: David Mallard Location/Address: Peoples Creek Road -27006
Proposed Facility: Residence Property Size: 120x250x285x
**NOTE * This Tmprovem4enf/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.
`L �
Residential Specifica ' n: Building Type /4 #People #Bedrooms y #Baths `�
Dishwasher: Garbage Disposal- Washing Machine -M ------Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size ;01a --c Type Water Supply_ Design Wastewater Flow (GPD) — Site: New Repair ❑
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth Linear FttC�V
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 u 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.****
Environmental Health Specialist's Signature: Date: ,-�-
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900259 Tax PIN/EH #: 5789-52-8843.01
Billed To: David Mallard Subdivision Info: Falling Creek Sec -1 Lot # 1
Reference Name: David Mallard Location/Address: Peoples Creek Road -27006
Pro Dosed Fnrility- Rocirlo.,..s
ATC Number. 2420
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 WASTEWATE NSTRUCTION IS VALID F.QRA PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: 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. �/l
r
E:J
Septic System Installed By:
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & AT 22 R nn M R
• LK � l5 u l'1 l5
Davie County Health Department D
Environmental Health Section
P.O. Box 848/210 Hospital Street 2000
Mocksville, NC 27028
(336) 751-8760 ENVIRONMENTAL HEALTH
DAVIE COUNTY
***nWORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed _OW 1 d S. XIA4 �,ege' Contact Person
Mailing Address 11� �_� » c�/�_ Home Phone
City/8tate/2IP Business Phone ?Y-3�d %g
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: r,: Site Evaluation
1;-
City/state/Zip
Ximprovement Permit/ATC ❑ Both
4. system to service: --13, House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _-3 # Bathrooms
—tl Dishwasher ---H Garbage Disposal --44 Washing Machine --" Basement/Plumbing II Basement/No Plumbing
6. If Businesa/Industry/Other: Specify type
# Co—odea
# showers
# Urinals
# People # Sinks
# Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of Water supply: _)R County/City ❑Well ❑ Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes --% No
If yes, what type?
***IhIPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: /o?a ec- %'5--0 /10;2 WRITE DIRECTIONS (from
Mocksville) to PROPERTY:
Tax Office PIN: #S7Ut,. 2-- .3 .Ol� 7 Y7 Lt%
Property Address: Road Nam 4y��o,0%S�%���`� g0 T
CityfLip /7 4'1�G�7oO6' �� 62O
If in a Subdivision provide information, as follows:
Name: SbWC111✓% e C! '(n 0
Section: �� Block: Lot: Date Property Flagged: ��2--
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. 1, also, understand that 1 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 b
to conduct all testing procedures as necessary to determine the site sui 1i
'5
DATE - /— Zed SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
3o Site Revisit Charge
Revised DCHD (07/99)
Date(s):
I Client Notification Date:
`EUS:
Account No. �f
Invoice No.
41P
170 Y. TW/
COW 17q rq !37
4y 4J/
/
4z \(O
/ Q /
+ Y
APPLICANT INFORMATION
Account #:
989900259
Billed To:
David Mallard
APPLICANT INFORMATION
Account #:
989900259
Billed To:
David Mallard
Reference Name:
David Mallard
Proposed Facility:
Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
Property Size:
PROPERTY INFORMATION
Tax PIN/EH #: 5789-52-8843.01
Subdivision Info: Falling Creek Sec.1 Lot # 1
Location/Address: Peoples Creek Road -27006
120x250x285x Date Evaluated:
I
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit c/� Cut
FACTORS 1 2 3 4 5 6 7
Landsca a position L47
Slope %
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
SITE CLASSIFICATION: f
LONG-TERM ACCEPTANCE RATE: /
REMARKS:
EVALUATION BY: &04
OTHER(S) PRESENT:
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 05/99 (Revised)
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT n n 2
:�- - Davie County Health Department
Environmental Health Section �—
P.O.Box 848 AUG _ 6 1997
Mocksville,NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE
.;
ALL THE REQUIRED INFORMATION IS PROVIDED.
' 1. Name to be Billed �.esV'//%e Lt) 4be✓e �n, Contact Person 6,-)4
' Mailing Address Home Phone 9gtt•' 6416g
City/State/Zip i+✓s o it/ -56 Al e, Q 7/0 3 Business Phone 9 9�? 6 7
2. Name on Permit/ATC if Different than Above Soo m.--
? Mailing Address City/State/Zip
3. Application For: 0' Site Evaluation ❑ Improvement Permit&ATC 0 Both
i ' •
j
4. S-stem to Serve: ❑ House ❑ Mobile Home _A ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
14 i
1
6. l"'iusiness/Other: Specify type ' # People # Sinks
# Commodes # Showers # Urinals # Water Coolers'
.i
I` -oodservice: # Seats Estimated Water Usage(gallons per day)
7. Type of water supply: ❑ County/City `` ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes •i ❑ No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
- SUBMITTED WITH THIS APPLICATION.
i
'1 Property Dimensions: q9, Z 7q gtN� 1 WRITE DIRECTIONS(from
- r 1 Mocksville)TO PROPERTY.—
Tax Office PIN: # � 7 9!J63 J 7 o 3 1
1 C e
Property Address: Road Name P�rfZ-�L� t�Le� �c�- • 1
City/Zip JV;4wV —
1 r
If in Subdivision provide inform tion,as follows: �/��5 1
i4ame:
Section: ,/ Lot # _
1
:i .
This i..;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 .
}
l falsified or changed.I,also,understand that I am responsible foi•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 dad to conduct all testing,,procedures
as necessary to determine the site suitability.
DATE g—��cl SIGNATURE
Revised DCHD(06-96)
c 7iczd a�
S
} - a
�� C G CS Owls APPLICATION Fen SEI?e EVALUATION/IMPROvEMENT mw&ATC D
Mav;e County Health Department
B.®Bos°®m8entao Knew ffi Se+c6►ont AUG 3 11999
X22 Mocksville, NC 27028
taL (336)751-8760
t
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCCOMID UNLESS ALL TSE REQUIRED
ItZ r&=ION IS nED. Refer to the INB'ORMATIou BULLETIN for instructions.
1. Name to be billed Contact Person �SS.f�ifi /Liv
Nailing Address some It'hone Q
City/state/sap Y.•IA�C.L 27LPJ bwiness Rhona J p(57--
Z. !tame on Perai2/ATC It Different than Above
Failing AditessCity/8 /sip
s. ]tppiiertion ror: 13 Site evaluation Improvement permit/ATC 13 Both
a. system to'service: .ff House O Mobile Home O Business 0 industry 0 Other
a. If Residence: # People ? # Bedrooms 66 .3 # Bathrooms 2
S Dishwasher �earbage Disposal QVIfaahiag Machine O 8aseaent/plumbing O Hasement/No VIuabing
S. If business/Industry/Othes: specify type # ROMIG # sinks
# Commodes # showers # urinals # Mater Coolers
Ilr rOODSERVICE: g Seats Estimated Water Usage (gallons per day)
7. Type of Mater supply: Q'County/City 0 Well 0 Community
9. Do you anticipate additions or expansions of the facility this system Is intended to serve? 0 Yes fJNo
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUB11HIM by the client with THIS APPLICATION.
Property Dimensions: WRITE DIRECTIONS(from Moclumille)to PROPERTY:
Tax 08fce PIN: # k P>1�3 TM J IAV
Property Address: Road Name/��G,o% C/'e,�11�Cl,
City/Zip
If in a Subdivision provide information,as follows: Till 1 �-r is '7V tier
Name: !
Section: Block: Lot: Date Property Finned:
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,tenderstand that I ant nslble jar all charges Incurred jroni
this appHcadon. I,hereby,give consent to the Authorized Representative of the a oanty$ealth partment
to eater upon above described property located in Davie County and awned by �,_
to conduct all toting procedures as necessary to determine the site suitability.
DATE �/�� SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Reylsit Charge
Date(s): Of 9
- 1 1-7D
As Client Notiflestion Date:
- I/-7
Lig/ EHS
Account Na
2A`C.C•-�
Revised DCHD(07/99) Invoice No.
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME l� �Y/I`�� DATE EVALUATED6�/
PROPOSED FACILITY y� PROPERTY SIZE
SUBDIVISION -ell ROAD NAME ��'�. � ` ✓l�
Water Supply: On-Site Well Community Public t/
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope% t!:I-
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON 11 DEPTH Y- 3 r
Texture grouC
Consistence _
Structure Si/G
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 ,QC/
SITE CLASSIFICATION: y J EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: ) OTHER(S)PRESENT:
REMARKS: c°P
L END
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)
s _r,•�� r- W1\ 0',v{� ; V'!L N .19'05"E ^_3
\
PUBLIC R W 505.11'
123.00 � 100.00' 2
C—> lr .. 04C,c
65
vi 9'
3
in
0.704 Ac.t
J
l phi
N
CN Z x292 3 99.
oN ~0 692 Ac.t 01
0.692 Ac.t N � Y � .00
CN 00 00 'a0 � 0.6 9 2 A c.f VL
z Z11.7g tri �o� Q4� S59'0
03 99. 6
o 6Z
126.38
51.79'
1^3.37
> ..
50.00'1 M --
NO'
�2a Q1
0 ''.
2 3
t; .
Ili
SO1'21 01� E 3in
0.693 Ac. F `
o /
8 20
o-00
i
.y? 88' .^� Ate.
Z� w 92711VP
, o
9oS30
pS.�Y 0.707 A
rn c.t 30-
CIO
o C,)LO
/
* 01\ 74.18'
187.34'
LO
3 261.52'
►� j o -- eo 33_t
3'
ccS89N04'16'00"E 4'0
4/W
�GpO�� Z Parcei 44' �� Q
C, Richard M. Talbert I 00 OCertificate of Approval oy = ^ung Board:
D8 170, P9 853 Cd /
The Davie County Planning Boara hereby approves
��-\0 / �� Record Plot for FollingCreek ;arm subdivision
I AZ
C, -�=�---�---:_— r •.,
Q��. /
Date Chairman. Cob^ty Planning Board
Q7 444
°
SEARING O
410'5 2 W 4 2�co CQ Certification of Approval of Private (on site) Sewage Disposal System•
x'13 05 W L.
5'39'49-E l �O� V�Qv O / ! hereby certify that the Davie County Health Department has 9R6uated
subdivision entitled FollingCreek Form with respect to,Crit and conditi
x'26 02 W i A.° �° / established by state !ow or promulgated thereunder POP the some is fo
3• f Q to comply with such criteria and n EP• .oi
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT TLS n n 17 2
Davie County Health Department
Environmental Health Section
P.O.Box 848 AUG - 6 1997
Mocksville,NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE
� //
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed u/0esr('1/;e W 'bey�asx OA� 2. Contact Person G V 1A
Mailing Address ,2,qt5- 5-JVh 2l Home Phone 9 99—
City/State/Zip L/i iN i/ Si4 e, Q 7113 Business Phone 9 9�1' S 7
99�-alio
2. Name on Permit/ATC if Different than Above .54 m.o--
Mailing Address City/State/Zip
3. Application For: 2--'s'ite Evaluation ❑ Improvement Permit&ATC ❑ Both
4. System to Serve: ❑ House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # 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: ❑ County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
/,� SUBMITTED WITH THIS APPLICATION.
Property Dimensions: %9, 7q Jltee.5 1 WRITE DIRECTIONS(from
� Mocksville)TO PROPERTY:
Tax Office PIN: # 7 11!J _ - 63 - �7 o,3 1
Property Address: Road Name �-� G �- • C / G
rf��City/Zip l�dyow e✓ NC . �7dB( i l
If in Subdivision provide tion, follows: ` / S 1
OR/� de�A
Name: CIlly
;r6i'
-rrf° 1
t
' 1
Section: Lot #: AIR �
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 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 suitability.
DATE V-6-9 2 SIGNATURE
Revised DCHD(06-96)