195 Palomino Road Lot 4Davie County, NC Tax Parcel Report Thursday, January 26, 2017
234 1 / 14S { 18835'
;•�156{- 198'
23 8 �.ti 1�r--,,_- .-155 r, �F 199
23 7 1 158 -
159 157 f E02' 203
195
i
183
I 225
---250 F'!t
WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number.
H9090A0004
Township:
NCPIN Number:
5789851035
Municipality:
Account Number:
8304408
Census Tract:
Listed Owner 1:
PROCTOR RUSSELL C
Voting Precinct:
Mailing Address 1:
195 PALIMINO RD
Planning Jurisdiction:
City:
ADVANCE
Zoning Class:
State:
NC
Zoning Overlay:
Zip Code:
27006
Voluntary Ag. District:
Legal Description:
LOT 4 HIDDEN MEADOW
Fire Response District:
Assessed Acreage:
5.00
Elementary School Zone:
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
Land Value:
Total Assessed Value:
12/2014 Middle School Zone:
009740945 Soil Types:
0007 Flood Zone:
238 Watershed Overlay:
Outbuilding & Extra
Freatures Value:
Total Market Value:
Shady Grove
37059-804
EAST SHADY GROVE
Davie County
DAVIE COUNTY R -A
ADVANCE
SHADY GROVE
WILLIAM ELLIS
PcB2,PcC2
DAVIE COUNTY
No
Davie County,
Ail data is provided as Is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the
Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
F-al
NCor
County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to
arising out of the use or Inability to use the GIS data provided by this webshe.
I.-- — — 1
a
OPERATION PERMIT
y�o Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Russ Proctor/Ferrell Clay
Address: 29 Tannerhaum Circle
City: Greensboro
State/Zip: NC 27410
Phone #: (336) 682-7822
Address/Road #:
195 Palomino Drive
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
*Water Supply: NEW WELL
*IP Issued by: 2140 -Nations, Robert
*CA issued by: 2140 - Nations, Robert
For Office Use Only
*CDP File Number 175247 - 1
H9 -090 -AO -004
County ID Number:
Evaluated For: NEW
Township:
/'Property Owner: Robert and Beverly Sandoz
Address: 353 Jonestown Rd, # 206
City: Winston-Salem
State/Zip: NC 27104
Phone #:
ierty Location & Site Information
Subdivision: Hidden Meadow Phase: Lot: 4
Design Flow: 4 8 0
Soil Application Rate: 0 a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Directions
Hwy 158 East, right on Hwy 801. Left on 2nd
Peoples Creek Rd. Left on Dublin Rd, Right on Irish
Place to Palomino at end
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? O Yes (9 No
*Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required?
O Yes X No
*Pre -Treatment:
Drain field
1 7 4 5 Sq. ft.
5
450ft.
9 Q Inches O.C.
®Feet O.C.
3 Qlnches
® Feet
Aggregate Depth:
inches
Minimum Trench Depth:
3
6
Inches
Minimum Soil Cover:
a
4
Inches
Maximum Trench Depth: 3
6
Inches
Maximum Soil Cover:
a
4
Inches
Page 1 of 4
*System Type: BIDIFUSER STANDARD
Installer: Nick Ward
Certification M
*EHS: 2140 - Nations, Robert
Date: 0 8/ 1 4/ x 0 1 5
Approval Status
® Approved ❑ Disapproved
CDP File Number 175247 - 1
Manufacturer:
WMs
Dosing Volume:
STB:
960
PT:
Gallons:
1000
Certification #:
Date:
0 7/
1 4/
x 0 1 5
*Filter Brand:
*EHS:
Date:
❑
ST Marker:
❑ Yes
®
No
nforced Tank:
❑ Yes
®
NO
1 Piece Tank:
❑ Yes
®
NO
Yes
❑
NO (Min. 6 in.)
County ID Number: H9 -090 -AO -004
)tic i anK
Lat.
Long:
Installer: Nick Ward
Certification #:
*EHS: 2140 - Nations, Robert
Date: 0 8/ 1 4/ x 0 1 5
Pump Tank
Manufacturer:
Dosing Volume:
Installer:
PT:
*Chain:
Certification #:
Gallons:
❑
Yes
Flow Adjustment Valve
❑
*EHS:
Date:
❑
/
PVC Unions
/
Date:
Riser Sealed
❑
Yes
❑
No
Yes
Riser Height:
❑
Yes
❑
NO (Min. 6 in.)
Approval Status
nforced Tank:
❑
Yes
❑
No
❑ Approved O Disapproved "
1 Piece Tank:
❑
Yes
❑
NO
/ Pipe Size: inch diameter
Pipe Length: feet
*Schedule:
Pressure Rated ❑ Yes ❑ NO
Approved fittings ❑ Yes ❑ No
/ Pump Type:
/
Dosing Volume:
Draw Down:
*Chain:
Valves Accessible
❑
Yes
Flow Adjustment Valve
❑
Yes
Check -valve
❑
Yes
PVC Unions
❑
Yes
Vent Hole
❑
Yes
Anti -siphon Hole
❑
Yes
Supply Line
Installer:
Certification #:
*EHS:
Date: /
Installer:
Gal Certification #:
Inches *EHS:
/
Date:
❑ No
❑ No
❑ No Approval Status
❑ No ❑ Approved ❑ Disapproved
❑ No
❑ No
Page 2 of 4
CDP File Number 175247 - 1 County ID Number: H9 -090 -AO -004
Electric EauiDment
NEMA 4X Box or Equivalent
❑
Yes
❑
NO
Installer:
Box 12 inches Above Grade
❑
Yes
❑
NO
Certification #:
Box Adj. To Pump Tank
❑
Yes
❑
No
Conduit Sealed
❑
Yes
❑
No
*EHS:
Pump Manually Operable
❑
Yes
❑
NO
*Activation Method:
Date.
Approval Status _.
Alarm Audible
M—Ye
s
E-1NO
° Cl
Approved ❑ Dlsapprovetl
Alarm Visible
❑
Yes
❑
No
2140 - Nations, Robert
*Operation Permit completed by:
Authorized State Agent:
Owner/Applicant Si
Date of Issue: 0 8/ 1 4/.2 0 1 5
This system has been installed in compliance with applicable NC General Statutes: Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1 900 et. Seq., and all conditions of the Improvement Permit and
Construction Authorization. This property is served by a TYPE ii A. sewage septic system.
Rule .1961 requires that a Type TYPE ii A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: N/A
Rule .1961 requires that a Type IV and V septic systems designed for a 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 life of the septic system.
Rule. 1961 (2) (e) requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system 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 O Import Drawing
**Site Plan/Drawing attached.**
Page 3 of 4
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Operation Permit
CDP File Number: 175247 - 1
County File Number: H9 -090 -AO -004
27028 Date: / /
0Inch
Scale: , , . O Block
0 N/A
Page 4 of 4 P1 P2 P3
CONSTRUCTIOTI
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Russ Proctor/Ferrell Clay Realtor
Address: 29 Tannerhaum Circle
City: Greensboro
State/Zip: NC 27410
Phone #: (336) 682-7822
Address/Road #:
Palomino Road
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
*Water Supply: NEW WELL
11 For Office Use Only
*CDP File Number 175247 - 1
County ID Number: H9 -090 -AO -004
Evaluated For: NEW
Township:
PERMIT VALID UNTIL:
0 4/ a 1/ a 0 a 0
Property Owner: Robert and Beverly Sandoz
Address: 353 Jonestown Rd, # 206
City: Winston-Salem
State/Zip: NC 27104
Phone #:
Subdivision: Hidden Meadow Phase: Lot: 4
Directions
Hwy 158 East, right on Hwy 801. Left on 2nd Peoples
Creek Rd. Left on Dublin Rd, Right on Irish Place to
Palomino at end
*Proposed System: 25% REDUCTION
Nitrification Field 1 7 4 5
Sq. ft.
Septlc an 1 0 0 0
Gallons
1 -Piece: O Yes ® No
Pump Required: O Yes (& No O May Be Required
Pump Tank: Gallons
No. Drain Lines 5 1 -Piece: OYes ONo
Total Trench Length: 4 3 6 ft, GPM --vs— ft. TDH
Trench Spacing: _ 9 Inches O.C.
Feet O.C. Dosing Volume: _ Gallons
Trench Width: _ 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre -Treatment: O NSF OTS -1 O TS -11 /
Septic Tank Installer Grade Level Required: 01011 O 111 01V
Page 1 of 3
Minimum Trench Depth:
a
4
\
Site Classification:
Provisionally suitable
Inches
Minimum Soil Cover:
1
a
Saprolite System?
OYes (9 No
Inches
Design Flow:
4 8 0
Maximum Trench Depth:
3
6
Inches
Soil Application Rate:
0 a 7 5
Maximum Soil Cover:
a
4
Inches
*System Classification/Description:
*Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
*Proposed System: 25% REDUCTION
Nitrification Field 1 7 4 5
Sq. ft.
Septlc an 1 0 0 0
Gallons
1 -Piece: O Yes ® No
Pump Required: O Yes (& No O May Be Required
Pump Tank: Gallons
No. Drain Lines 5 1 -Piece: OYes ONo
Total Trench Length: 4 3 6 ft, GPM --vs— ft. TDH
Trench Spacing: _ 9 Inches O.C.
Feet O.C. Dosing Volume: _ Gallons
Trench Width: _ 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre -Treatment: O NSF OTS -1 O TS -11 /
Septic Tank Installer Grade Level Required: 01011 O 111 01V
Page 1 of 3
CDP File Number 175247 - 1
•H9 -090 -AO -004
County ID Number:
❑ Open Pump System Sheet
uired:®Yes ONO ONO, but has Available Space
*Site Classification: Provisionally Suitable
Design Flow: 4 8 0
Soil Application Rate: 0 a 3 5
*System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Nitrification Field 1 7 4 5
Sq. ft.
No. Drain Lines 5
Total Trench Length: 4 3 6
ft.
Trench Spacing: 9 O Inches O.
0 Feet O.C.
Trench Width: 3 Inches
Feet
Pump Required: OYes O No ® May Be Required
Pre -Treatment: O NSF OTS -1 OTS -II
*Site Modifications
en
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. ReTB
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. Charadm
Remaining
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? Oyes ONo
Applicant/Legal Reps. Signature: Date:
*Issued By: 2140 - Nations, Robert Date of Issue: 0 4 / a 1 / a 0 1 5
Authorized State Agent: Malfunction Log OYes
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
Aggregate Depth:
inches
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
a
4
Inches
*Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
Pump Required: OYes O No ® May Be Required
Pre -Treatment: O NSF OTS -1 OTS -II
*Site Modifications
en
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. ReTB
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. Charadm
Remaining
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? Oyes ONo
Applicant/Legal Reps. Signature: Date:
*Issued By: 2140 - Nations, Robert Date of Issue: 0 4 / a 1 / a 0 1 5
Authorized State Agent: Malfunction Log OYes
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 175247 - 1
County File Number: H9 -090 -AO -004
Date: 04 /,2 1/,2015
O Inch
Scale: O Block
O N/A
t1
v l CONSTRUCTION AUTHORIZATION I . . N, i:i, k
v Davie County Health Department W Q V
210 Hospital Street CDP File Number: 175247 - 1
P.O. Box 848 H9 -090 -AO -004
ocksvill NC 27028
Cou File Number:
potV to C- �► �,c.� � 1-4 C.'a y -,C ci.�. 5 v OL U
IDDate:.04/a1/a015'7`'A
Click below to import In(irn"agef6rorn an external location: Drawing Type: Construction Authorization
/ f Gt V e I baC, G J ��
- e> `lo P o -C j a 04 -e
Page 3 of 3
1 gs
P1 P2
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.Q. Box 848
W
Mocksville NC 27028
/" For Office Use Onlv
'CDP File Number 175247-1
County ID Number: H9-090-Ao-004
Evaluated For: NEW
s Township:
Phone: 336-753-6780 Fax: 336-753-1680 w .0 4 V/ „ar 1/ a 0 a 0
Applicant: Russ Proctor/Ferrell Clay Realtor
Address: 29 Tannerhaum Circle
City: Greensboro
State/Zip: NC 27410
Phone #: (336) 682-7822
1 Address/Road #:
Palomino Road
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
"Water Supply: NEW WELL
Property Owner: Robert and Beverly Sandoz
Address: 353 Jonestown Rd, # 206
City: Winston-Salem
State2ip: NC 27104
Phone #:
Subdivision: Hidden Meadow Phase: Lot: 4
Directions
Hwy 158 East, right on Hwy 801. Left on 2nd Peoples
Creek Rd. Left on Dublin Rd, Right on Irish Place to
Palomino at end
'Provisionally
Minimum Trench Depth:
a 4 Inches
\Site
Classification: Suitable
Saprolite System? OYes @No
Minimum Soil Cover
1 a Inches
Design Flow: 4 8 0
Maximum Trench Depth:
3 6 Inches
Soil Application Rate: 0 - a 7
5
Maximum Soil Cover:
a 4 Inches
'System Classification/Description:
'Distribution Type:
GRAVITY- PARALLEL (eq. d -box)
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY
OR 480 GPD OR LESS) Septic Tank:
1 0 0 0
_ _Gallons
`Proposed System: 25% REDUCTION
1 -Piece:
OYes (j) No
-
Pump Required: OYes
@No OMay Be Required
Nitrification Field 1 7
4
5 Sq. ft. Pump Tank:
Gallons
No. Drain Lines 5
1 -Piece:
Oyes ONo
Total Trench Length: 4 3 6
f{
GPM—vs—
ft. TD
Trench Spacing: _
9
0Inches t O CC. Dosing Volume:
_ Gallons
Trench Width:Inches
3
gFeet
_
.
Grease Trap:
Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS -1 OTS -11
Septic Tank Installer Grade Level Required: 01
O11 0111 OIV
Drina 1 of Q
CDP File Number 175247 - 1 County ID Number: H9 -090 -AO -004
❑ .Open Pump System Sheet
air5vslem Kequtrea:V Tub %.Jivu vniu, uu[ rids mvdriduit: opdatr
za.. Trench Spacing:
*Site Classification:Provisionally Suitable _ 9 Feet eO.C.
Trench Width: QInches
Design Flow: d R B V Feet
Total Trench Length: 4 3 6 ft
Pump Required: Oyes ONo @May Be Required
Pre Treatment: ONSF OTS -1 OTS -II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance Of this permit 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.
This Authorization for Wastewater System Construction shall bevalid fora person equal to the period of validity of the improvement Permit, not
to exceed live years, and may be issued at the sun etime 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 fora 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 (.1837(g)). The person owning or controlling the system shall be responsible forassuring compliance
with the laws„ rules, and permit conditions regarding system location. Installation, operation, maintenance, monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. Signature: Date: , /
*Issued By: 2140- Nations, Robert Date of Issue: 0 4 / a 1 / a 0 1 5
Authorized State Agent: Malfunction Log OYeS
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
Aggregate Depth:
Soil Application Rate: 0 a 7 5
inches
.�
Minimum Trench Depth:
a
4
*System Classification/Description:
Inches
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS) Minimum Soil Cover
1
a
Inches
Maximum Trench Depth:
3
6
*Proposed System: 25% REDUCTION
Inches
Maximum Soil Cover:
a
4
Nitrification Field 1 7 4 5
-
. Inches
Sq. ft.
No. Drain Lines
*Distribution Type:
GRAVITY - PARALLEL (eq. d -box)
5
Total Trench Length: 4 3 6 ft
Pump Required: Oyes ONo @May Be Required
Pre Treatment: ONSF OTS -1 OTS -II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance Of this permit 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.
This Authorization for Wastewater System Construction shall bevalid fora person equal to the period of validity of the improvement Permit, not
to exceed live years, and may be issued at the sun etime 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 fora 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 (.1837(g)). The person owning or controlling the system shall be responsible forassuring compliance
with the laws„ rules, and permit conditions regarding system location. Installation, operation, maintenance, monitoring, reporting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. Signature: Date: , /
*Issued By: 2140- Nations, Robert Date of Issue: 0 4 / a 1 / a 0 1 5
Authorized State Agent: Malfunction Log OYeS
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Construction Authorization
CDP File Number: 175247 -1
County File Number: H9 -090 -AO -004
Date: 0 4/.2 1/ 2 0 1 5
Q Inch
Scale:Q81ock ft.
QN/A
i
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II
III
II
II__
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it
Well Construction Permit
Davie County Health Department
UV210 Hospital Street
P.O. Bax 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
r
Property Owner; Russ and Rhonda Proctor
Address 27 Tannenbaum Circle
City: Greensboro
State/Zip: NC 27410
Phone #:
*CDP File Number 175247
PIN Number. H9 -090-A0-004
Tax Lot #: Tax Block #:
Evaluated For: WELL
PERMIT VALID UNTIL: 4/21/2020
ant:
Walraven Signature Homes
ss:
F
PO Box 2115
y
Kernersville
State/Zip:
NC 27285
Phone #:
(336) 8044-0471
Property Location & Site Information
Address/Road #: Subdivision: Hidden Meadow Phase Lot: 4
Palomino Road
Advance NC 27006
Site Address: Palomino Road
*Proposed use of Well:
Directions if Other:
Directions: Hwy 158 East, right on Hwy 801. Left on 2nd
Peoples Creek Rd. Left on Dublin Rd, Right on Irish
Place to Palomino at end
Well Contractor Information
Drilling Contractor Driller Registration
1 J r. t t t t t t t t t r e t
Permit Conditions
*Permit Conditions
Well location, construction and protection must meet all state and local_ regulations and must be Inspected and approved by an authorized representative of
the Local Health Department. The permit maybe revoked at any time for (allure to complywith existing regulations. The siting 'of approved well construction
area(s) by the Health Department Is to provide protection from the known possible sources of contamination. The approved well area(s) may not be changed
without written permission from an authorized representative of the Local Health Department. No volume of quality of water is guaranteed by the Health
Department.
*Issued By: 2140 - Nations, Robert *Date of Issue{ 0 , 4 , % , 2 , 1 , / , a , 0 1 5
Authorized State Agent: @Hand Drawing 0Import Drawing
Owner/ApplicantSignaturec.. 1 **Site Pian/Drawing attached.**
WELL CONSTRUCTION PERMIT
Davie County Health Department
Hospital Street
P.O. Box 848
Mocksville NC 27028
rwa+ oa®r
Drawing Type: Well Permit
CDP File Number: 175247
County File Dumber: H9 -090 -AO -004
Date:04!2112015
Oinch
Scale: QBlock
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Rt:�CZIVED APPLICATION FOR PRIVATE WELL PERMIT
ArFR 14 2015 Davie County. Environmental Health
P.O. Box 848/210 Hospital Street
DC HEALTH Mocksville, NC 27028
(336)753-6780 / Fax (336)753-1680
***IMPORTANT***
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED.
APPLICANT INFORMATION
Name \A(AL.V-A\IE-v.J Contact Person _KL=F-r JA --J dos -,-6,z
Address�O o� 7 -T -t t c Home Phone
City/State/ZIP tnty ittyLsV-.Le- N C- 2-7 Z 7 S Business Phone 336 <Lp,-( a ? 1
Name on Permit if Different than Above
Mailing Address 'City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accom any this application. Included: Site Plan ❑Plat (to scale)
Owner's Name 1\0sS a-hC-76a- Phone Number
Owner's Address 2 -7 "i'A� tOer j MI) Nl (' arc- City/State/Zip 6 (tt-cN S r3 m� a Nc -Z-7q10
Property Address Loa 9 I2A t- oAA.4.,j \:) eft , City &\,L a ,-
Lot Size , p 1 PSL Tax PIN# iR q 1, go Aonoy
Subdivision Name(if applicable) Section/Lot# .
Directions To Site:
DEVELOPMENT INFORMATION
Permit Type: New Well Well Repair Well Abandonment Other (specify)
Facility Type: Residential C Food Service Church Commercial Other
Are There Any Septic Systems Currently On The Site? YES NO '><
Do You Intend To Install A New Septic System On This Site? YES �_ NO
TERMS AND CONDITIONS:
This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines
with dimensions, the specific location of the facility and any existing or future appurtenances, the location of any existing septic
system, sewer lines, water lines, any existing water supplies and any surface waters. The applicant is responsible for identifying
and marking the property lines and corners. The applicant is responsible for making the site accessible:
By signing this application, the applicant signifies that they understand the terms and conditions and that they give permission for
Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to
determine the best location for a well.
ed Date
7/30/09
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account 4
Invoice 4
v IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
( For Office Use Only
"CDP File Number 175247-1
County ID Number: H9 -090 -AO -004
Evaluated For: NEW
Township:
Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 12/3/2019
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with, this Improvement Permit.
Applicant: Russ Proctor/Ferrell Clay Realtor
Address: 29 Tannerhaum Circle
City: Greensboro
State2ip: NC 27410
Phone #: (336) 682-7822
Address/Road #:
Palomino Road
Advance NC 27006
Structure: SINGLE FAMILY
# of Bedrooms: 4
# of People:
"Water Supply: NEW WELL
%Property Owner: Robert and Beverly Sandoz
Address: 353 Jonestown Rd, # 206
City: Winston-Salem
State/Zip: NC 27104
Phone #:
I—
Subdivision: Hidden Meadow Phase: Lot: 4
: Provisionally Suitable
Saprolite System? OYes @No
Design Flow: 4 8 0
Soil Application Rate: 0 a 7 5
u
'System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 25°Jo REDUCTION
Directions
Hwy 158 East, right on Hwy 801. Left on 2nd Peoples
Creek Rd. Left on Dublin Rd, Right on Irish Place to
Palomino at end
Minimum Trench Depth: 2 4 Inches
Maximum Trench Depth: 3 6 Inches
Septic Tank:
1 0 0 0 Gallons
1 -Piece: OYes (j)No
Pump Required: OYes (j) No OMay Be Required
Pump Tank: Gallons
1 -Piece: OYes ONo
Repair System Required:®Yes ONo ONO, but has Available Space ,'..
RepairSystem
.Site Classification: Provisionally Suitable
Soil Application Rate: 0 - a 7 5
'System Classification/Description:
TYPE III B. SYSTEM W/SINGLE EFFLUENT PUMP
'Proposed System: 25% REDUCTION
Minimum Trench Depth: a 4 Inches
Maximum Trench Depth: 3 6 Inches
Pump Required: @Yes ONo O Maybe Required
i
Pagel of 3
CDP File Number 175247 - 1 County 1D Number: 1-19-'090-Ao-004
*Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this perm it by the Health Department in no way guarantees the issuance of other permits. The perm it holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
Site Plan "'Improvement Permit shall be %Gild for 5 years from date of Issue with a site plan (means a drawing not necessarily drawn to
O scale that shows the existing and proposed property lines with dimensions, the location ofthefacility and appurtenances, the
site forthe proposed Wastewater system, and the location of water supplies and surface waters).
Plat The Improvement Permit shall be valid without expiration with plat (means a property surveyed prepared by a registered land
surveyor, drawn to a scale of one Inch equals no morethan 60 feet that includes: the specific location of the proposed facility
O and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters. Plat
also means, for subdivision lots approved by the local planning authority and recorded with the county register of deeds, a copy
of the recorded subdivisions plat that Is accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may impose conditions on the Issuance and may revoke the permits for failure of
the system to satisfy the conditions, the rules, or this article. This permit is subject to revocation If the site plan, plat or Intended
use changes (NCGS 130A -335(o). The person owning or controlling the system shall be responsible for assuring compliance
with the laws, rules, and permit conditions regarding system location, installation, operation, maintenance, monitoring,
reporting, and repair (.1938(b)}
Applicant/Legal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. Signature: Date: / /
"Issued By: 2140 - Nations, Robert
Authorized State Agent:
Date of Issue: 1 a/ 0 3/ a 0 1 4
OValid without Expiration?
O Create CA?
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Improvement Permit
CDP File Number: 175247 - 9
County File Number: H9 -090 -AO -004
Date: I 1
Olnch
Scale: OBiock
ONIA =
FF
__.
II
-7-1 - - - - - -
- - - - - - -
- - - - - - --
............. . ......... .
i
............. . ..
. . ... .... .. ..... . . ... .......... .
......... . ...
..... . .....
. ....... .
. ... ... -
F -N�Nh.e
�----- `,asz
Vil&
III
----
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I�,,III
VLV.0J1VV,''QPPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health,.
✓ P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780L:Fax (336) 753-1680 '
Application For. to uation/Improvement Permit D Authorization To Construct(ATC) Both
Type of Application: ew System ❑Repair to Existing System DExpansioNModification of Existing System or Facility
CArrg++-
owev,
•' •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 I t&Z.a".7 I ✓b > Contact Person I•ri1Y'r%l l li i �j
Billing Address y ei 1' G Home Phone
City/State/ZIP a Al 1or'L AfC-. ,n7!}i?; Business Phone TZ7 U. -IF 2 1
Name on Permit/ATC if Dr erent than Above
Mailing Address Z' IG_nv-n htu rr>` e- City/State/Zip ^ ex bv,0 NC. i
PKUYEKI Y 1NFURMA I ION `Date House/Fad ity Comers Flagged
NOTE: A survey plat or site plan must accompany this application. Included:.ASite Plan DPlat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name i~;r Phone Number
Owner's Address �•3),4 241C. City/State/Zip t
Property Address c Cit Q¢�CVCL4�ru
Lot Size L-,- Tax PIN# I-1-.1
Subdivision Name(applicable) ect..on(Lot#
Directions To Site: uLe 2 S l 1;1
t 9 1
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? Dyes �&o
Does the site contain jurisdictional wetlands? Dyes o
Are there any easements or right-of-ways on the site? ❑Yes: o
Is the site subject to approval by another public agency? ❑Yes o
Will wastewater other than domestic sewage be generated? Dyes �Ko
IF RESIDENCE FILL OUT THE BOX BELOW
r# People I # Bedrooms -_-'I— # Bathrooms ?L Garden Tub/Whirlpool. ON.
Basement: Dyes o Basement Plumbing: Dyes two
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 DAccepted DInnovative DAlternative ❑Other
Water Supply Type: D County/City Water kNewwell 0Existing Well O Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes
Ifyes, what type?
.ANO
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 ifthe site is altered, the intended use
changes, or if the information submitted in this application is falsified or changed. 1 hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
I a and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and
long and flaggiggpr staking the house/faf:ijFty location, proposed well location and the location of arty other amenities.
—Site Revisit Charge
Property owner's or owneo legal repAsentativc signature
Date(s):
// +I / 4 Client Notification Date:
Date EHS:
Sign given Dyes DNo Account # V 1
Revised 11/06 Invoice #
0 bri�Cheek lI//z/H
O
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13 RS aii L7 \� /
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398 00
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300.00'
298. 'E
g 84'08'30"
E 840.81 242.81''
a� 55.19,
LOU ELLA H. ANGEL
DB. 175, PG, 501
/ Z
10
APPUCATION FOR SITE EVALUATION/iNIPROVEMEN1, FEli $1T & A
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQi7T �uNly ""n
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed m hk' m e. V1 �� 1' (1_ � t � l ti. Contact Person
Mailing Address • D . /3�� j[ J Home Phone
City/State/ZIP (/C III t 2-7 z0b Business Phone .3 r /
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For
4. System to Service:
5. If Residence:
City/State/Zip
8"SSite Evaluation ❑ Improvement Permit/ATC n Both
/House ❑ Mobile Home ❑ Business ❑ Industry U Other
# People # Bedrooms # Bathrooms
U Dishwasher CI Garbage Disposal ❑ Washing Machine U Basement/Plumbing II Basement/No Plumbing
6. I£ Business/Industry/Other: Specify type
# People # Sinks
# Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water ZUsaa (gallons per day)
7. Type of water supply: ❑ County/City ll 11 Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUSQT�B�ESUBM17TED by the client with THIS APPLICATION.
Property Dimensions: Y� , C/ ACAS WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # :57ff i - `63- Z'L (v
[v -0q
Property Address: Road Name
City/zip 2-20o�P
If in a Subdivision provide information, as follows: ;-0,03
ia(dde.�
Name: Pip Ps ,q ,e n.4,227 .
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 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 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 by
to conduct all testing procedures as necessary to determine the site s�ui_tabilit .
2*0-7. I�
)ATE �� 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).
inD A C E
,,n
_s
d t blAY 2002
ENVIRONMENTAL HEALTH
DAVIE COUNTY
Revised DCHD (07/99)
Site Revisit Charge
Datc(s):
Client Notification Date:
EHS:
�
Account No. 1,- '/-y
-3
Invoice No. Z � to It
APPLICANT INVORMATION
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Account #:
990002073
Tax PIN/EH #:
5789-83-2266.04
Billed To:
Norman Building
Subdivision Info:
Peoples Ck. Farm Lot # 04
Reference Name:
HORIZON I DEPTH
Location/Address:
Peoples Creek Rd. -27096
Proposed Facility:
Residence
Property Size: see map Date Evaluated: S777/24—
% 4—
Consistence
Structure
Water Supply:
Water
On -Site Well
Community
Public
HORIZON II DEPTH
/
Evaluation By:
Auger Boring
Pit
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
CC
Slope %
HORIZON I DEPTH
- l�
• Z
Texture groupC
G(r
Consistence
Structure
Mineralogy1
HORIZON II DEPTH
• 22
Texture groupc
L
Consistence
�S
Structure
S
Mineralogyf
HORIZON III DEPTH
ZZ -
Texture groupC�
Consistence
(-r5
Structure
5, <
Mineralogy
HORIZON IV DEPTH
— f
Texture group
Consistence
r sS $
Structure
Mineralogy
SOIL WETNESS
Z -d
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
S
LONG-TERM ACCEPTANCE RATE
32E 1
SITE CLASSIFICATION: )
LONG-TERM ACCEPTANCE RATE: a
EVALUATION BY: v 7�
0,V444 -,C
OTHER(S) PRESENT: _�V1 G'i 144Zrc4_;'
REMARKS: P02 'bjV Zj SJQ�AeJ I41D ''h"�
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)
27.90'
51
HIDDEN MEADOW
PB 7 PG 238
:COQ ESSIpNq` ����'
SEAL
L-4217.
I%< s
•
uM.m ib• p�,
19
MARCH WOODS
18
MARCH WOODS
0000
/ .
pNLOI .�
HIDDEN MEADOW
PB 7 PG 238
LEGEND
Existing Iron Pipe
PK Nail Q
NOTES:
A) NO TITLE SEARCH WAS PERFORMED
BY THIS FIRM DURING THE COURSE
OF THIS SURVEY
B) THE PROPERTY SHOWN HEREON IS SUBJECT
TO ALL EASEMENTS OF RECORD ATTESTING
SAME.
C) THIS FIRM MAKES NO GUARANTEE AS
TO THE EXISTENCE OR LOCATION OF ANY
UNDERGROUND UTILITIES OR IMPROVEMENTS
ON OR ACROSS THIS PROPERTY. ANY
UNDERGROUND UTILITIES OR IMPROVEMENTS
SHOWN HEREON HAVE BEEN LOCATED FROM
VISIBLE EVIDENCE AND AVAILABLE
INFORMATION.
SITE PLAN
PROPERTY OF
WALRAVEN SIGNATURE HOMES
SHADY GROVE TOWNSHIP
DAME COUNTY, NORTH CAROLINA
GRAPHIC SCALE
en a ao eo im za
( IN FEET )
1 inch = 60 ft.