2160 Sheffield Road Lot 3 & 4Davie County, NC Tax Parcel Report Tuesday, January 31, 2017
WAK1V11Vki: TMS ILS 1VU'1' A SURVEY
Parcel Information
Parcel Number:
F100000065
Township:
NCPIN Number:
4890890793
Municipality:
Account Number:
30897600
Census Tract:
Listed Owner 1:
GRIGGS LONNIE GRAY
Voting Precinct:
Mailing Address 1:
2160 SHEFFIELD ROAD
Planning Jurisdiction:
City: HARMONY
Zoning Class:
State:
NC
Zoning Overlay:
Zip Code:
286349099
Voluntary Ag. District:
Legal Description:
LOT 3 HILLTOP ESTATES
Fire Response District:
Assessed Acreage:
0.90
Elementary School Zone:
Deed Date:
4/1996
Middle School Zone:
Deed Book / Page:
001860514
Soil Types:
Plat Book:
0008
Flood Zone:
Plat Page:
122
Watershed Overlay:
& Extra
Building Value: FO eatulres Va ue:
Land Value: Total Market Value:
Total Assessed Value:
Clarksville
37059-801
CLARKSVILLE
Davie County
DAVIE COUNTY R-20
SHEFFIELD - CALAHALN
WILLIAM R DAVIE
NORTH DAVIE
PcC2,CeB2
DAVIE COUNTY
�r
Davie County,
NC
All 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
County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to
or arising out of the use or Inability to use the GIS data provided by this website.
- DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax # (336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990003250
Billed To: Lonnie Griggs
Reference Name:
Proposed Facility: Residence
ATC Number: 4960
Tax PIN/EH #: 4890-89-9793.03
Subdivision Info: Hilltop Estates Lot # 3
Location/Address: Sheffield Rd. -27028
Property Size: 0.908 Acre
Site Type: ❑New ❑Repair ❑Expansion
**NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms # BathroomsD•,') # People Basement❑ Basement plumbing❑
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
4
Lot Size Type of Water Supply: ❑County/City Z<11 11 Community Well
/� 9'0
System Specifications: Design Wastewater Flow (GPD) "l 6 Q Tank Size dt"GAL. Pump TankGAL.fe r f I 1 .0
fPf
Trench Width G Max. Trench Depth_ 3Rock Depth et Linear t. �g a
Site Modifications/Conditions/Other: /43 cta2ed in 15A PiCAC :18,1.1M-)( 3 G 'o a3 99,4. vL
r^-r--pitd'3yvwT)s pja—y r sa at use
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30 — 9:30a.m. on the day of installation. Telephone # (336)751-8760.
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Environmental Health Specialist _ DaterJV
DCHD 11/06 (Revised)
'6
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760 Fax #(336)751-8786
OPERATION PERMIT
Account #: 990003250
Tax PIN/EH #:
4890-89-9793.03
Billed To: Lonnie Griggs
Subdivision Info:
Hilltop Estates Lot # 3
Reference Name:
Location/Address:
Sheffield Rd. -27028
Proposed Facility: Residence
Property Size:
0.908 Acre
ATC Number: 4960
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC has been installed
in compliance with Article 11 of G.S. Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems,"
but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of
time.
System Type:_ � S.T. Manufacturer �' Tank Date / Tank Size �i d •y d = 30
Pump Tank Size o ( J
�( JU ,
System Installed By: ' A r E.H. Specialist. Date: l a U I'G
U Li
DCHD 11/06 (Revised)
V1*1o1 N F
Applicata n For- a Evaluation/]
Type of A ication: ❑New System
'5 E EVALUATION/IMPROVEMENT PERMIT & ATC
D vie County Environmental Health
.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760/ Fax (33 51-8786
provement Permit uthorization To Construct(ATC) ❑ Both
❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed L 2ri ei r i.rte Contact Person Lem A t -e—
Billing Address a 1 O S e-{' ,'e& V Home Phone
City/State/ZIP f ma G a -T 3 ' Business Phone 704-S-90 '18S-0
Name on Permit/ATC if Different than Above,
Ciel wc� �r%4 ' 0—'
Address
City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name L OV1 G t Phone Number 7 O FflO ' l ra
Owner's Address City/State/Zi{at m e, ,JG % 3 41-
l.
Property Address o? City{
Lot Size R Tax PIN -
Subdivision Name(if ap licable) *11[Top E Section/Lot#
Directions To Site: PC:U-r,- STn ➢ F(ZI Ato S At' IC4 kL't"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?
[]Yes P<o
Does the site contain jurisdictional wetlands?
❑Yes 5Ko
Are there any easements or right-of-ways on the site?
❑Yes Dq<o-
Is the site subject to approval by another public agency?
❑Yes EiKo
Will wastewater other than domestic sewage be generated?
❑Yes (
TP R1P q FDF.Nf V PTT .T . C)T TT TAF. RCYY RF.T .OW
# People Ys..s y �L v # Bedroomsv # Bathrooms c7 Z Garden Tub/Whirlpool Comes []No
Basement: ❑Yes KINS Basement Plumbing: ❑Yes
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: (i�eonventional ❑Accepted ❑Innovative ❑Alternative ❑Other.
Water Supply Type: ❑ County/City Water ew Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 11<0 -
If yes, what type?
This -is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or 7ak�in a house/facility location, proposed well location and the location of any other amenities.
Site Revisit Charge
0 a, owner's or owner's legal qeliesentative signature
D
Date
ate(sy
Client Notification Date:
EHS:
Sign given ❑Yes ❑No Account # �—
Revised 11/06 Invoice #
GoMAPS - Davie County NC Public Access
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http://maps.co. davie.nc.usIGoMapslmap/Index.cfm?mainmapservice=gomaps&CFID=412... 3/16/2009
06/03/2004 07:49 33667
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P.
SIRG INC
FOR SITE EVALVAT(ON/IMPItovrME%iT PERMIT & plc
Davie County Health Department
Environmental Health SeWon
Box 848/210 Hospital Street
Mocksvillo, NC 27028
(334S) 751-0760 (3 r, 5'I- 0 I d�1�b'�•
_�%
PAGE 01
i*•IJyPORv�Eas PLICATION CANNOT' BS PR0 SSB.GD UNLESS ALL THE REQUIRED I
INPOltbtAT2 N OVIDSI). Refer to the INFORMATION BULLETIN for
instructions.
�/:. `I o b• Balled �IeLlta<� LN_^+��� Contact Person
Haillne� Address 2,40od !�� Itome Phoria 23JW
e""'CL ty/Seto/zzr k\q"f m,>.� N l a�' `�� y _ Business Phone
Name on penult/ATC if Diefstant (then Above_
v 1lnB
Address
�7^ Application Pars ,&Site Evpluation 13 Improvement Permit/ATC ED Both
�-4 system to Servicer Ll/ Houac ❑ Mobile Homo ❑ Business 0 znduntry ❑ Other
Type system requestedt U' Co*.ventional ❑ conventional modified ❑ innovative
,,Iff Residence. �/ x Peopl r _ ��� y o Bedrooms 4 Bothroome "2 '/Z
_4;9oishvasher t`7Carbags bisp.,sal m1 asbing Machine ❑Basemen t/Plumbing ❑Baas,ment/Ko Plumbing
7. It Businsss/Industry /other: verify typo 0 People M Sinks
M Commodes
0 :hower• a Urinals s Nater Coolers
IF FOODSERvrcz, k seats Estimated water Uoage (gallons per day)
rype of rater supply, ❑ Cour ty/City o/
Well ❑ Co=u' ni ty
ac you anticipate additions, or expansions of (lie fllcility Ibis syslen31s Intended to verve? 13 Yes O'fkn
11 y'cs, lyllai tyl)c7
***1A1P AN741* CLIL:NT:: fV OMPLL'TETHE REQUIRED P1tOPER1'Y INFORMATION IiIiQULS'1'lil)
OGLOW. F:i PL MUSTQES(/QMITTED by rho eticnt will+ TtieS APPLICATION.
L�perty Dim 11 '0113: 13 0 c DIflECT10rYS (£turn tLlacfcsviiicj to !rl(f)i'I'It'I'1':
is OI"lice P11v: B_6-? 317 it WQVV_
yylcrty Address: Road NantcIrA D StieS�,e 1 d Q !4 �_M� oe,_Qtrfc, �Y
"V
city/zipimc^ rfJc azto"),4
if in a Subdivision plovidc informaUot., AS rollOwll:
Section. Olocic: _ Lot. el i-�,Ome corners fingged:
This is to cerfif)• that the infornlatlon provided is correct to the best or n1v knorviedlic. I uttderstrind that tiny ljcl'lull(%)
issued hcrcnRcr arc subject to suspension or revocition, if tlic site plats or intended use 010139c, or if the iufor'lla Iloll
submi fled in this appllcatiou lc fals►tled or ch:tuged. ialso, aaraderstan/th?Barri rGrporttlbldJorn/l Chrrrgcs lrrcvra'rcr/guru
dds npplicrr/inn, I, borrby, rive consent to file Authorized Represcntativc of the Davie County Health Dcp:►rtmcnt
to cntcr upon above deycribcd property Ic :need It, Davie County and owned by _
In cunJuc! :11{ Icstiug procedures us neves, iry to dcterluiuc the site suitability,
o�/.,J -�/ ,�z3`/
I IP DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990003250 Tax PIN/EH #: 4891-80-3319.03
Billed To: Lonnie Griggs Subdivision Info:
Reference Name: Location/Address: 2140 Sheffield Rd. -28634
Proposed Facility: Residence Property Size: 135'x 330' Date Evaluated:
Water Supply: On -Site Well !/ Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1
2
3 4 5 6 7
Landscape position
Sloe %
?/
HORIZON I DEPTH
Y
Texture groupC
Consistence
10 41;r
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
7
SITE CLASSIFICATION: df
LONG-TERM ACCEPTANCE RATE: J V,
REMARKS:
EVALUATION BY:/ G/
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)
MEMO
MEMO
NONE
■■■■
MEMO
MEMO
■EM■
MEMO
Emus
NONE
NEON
■
■
NONE
MOON
moss
MESS
NEON
■EMEME■
■OM■E■■
■■MMEM■
SOMEONE
■■MME■■
■■■■■■■
■■MOMM■
■■MEM■■
■■M■■■■
No
No
ON
■
■■■■■ ■Nom■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
SSSS■ ■■■■■■■■■■■■■■■■■■
■E■■■ ■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
SSSS■ ■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■SSSS■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
EMEME SEMMES�iMEMNONON
■■■■■■■■■■■■■■■■■■■■■■■■■
SSSS■■■■No■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■■■
■■■■■ ■■■■■■■■■■■■■■■■■■
■■■■■■■■■■r■■■■■■■■
■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■U■■■■■■■
■■■■■■■■■■ ■■■■■■■
■■■O■■■■■■■■■■OO■■■
i
NEON
■■■■
■■■■
MOON
NEON
■■■■
■■■■
SEEM
moms
■
■
i
■
■
■
■
■
Environmental Health Section
P. 0. Box 848/210 Hospital Street
Courier 09-40-06
June 11, 2004
Lonnie Griggs
2140 Sheffield Road
Harmony, NC 28634
Re: Site Evaluation/ Sheffield Road —four lots
Tax Office PIN: #4891-80-3319
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on,
June 10, 2004 Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the sites, the sites were found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RBH/dlf
Enclosure(s)
4F
Davie County Health Department
/19 t836 Environlnelit,l Hec-Mi Sectioll
UP.0. Box 848
0 210 Hospital Street
} tP , Courier #: 0940-0(i
Mocksvillc, NC 27028
Phouc: (336) - 753 - 6780 I'm 036) 7.53-1680
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name: L py,G F 5 55 (� Phone Number �d `C 0 b — I c �v Home)
�
Mailing Address: 1 co tyr-.�lL�C a (Work)
Detailed Directions To Site: ��6 tic p _ X t�a AW -V ' m d S QwAk c— njtS kj a
Property Address:
Please Fill In The Following Information About The EXISTING Facility: ttnn
Name System Installed Under: Type Of Facility:/ tOttr�(r�`,tZ- l
Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People: ii
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following .Information
Type Of Facility:
Requested By: 0
(Sign )
Approved
Comments
The NEW Facility:
Number Of Bedrooms: Number of People
Date Requested: Z' .2 r, I t7
For Environmental Health Office Use Only
Environmental Health Specialist_ n'��Ti/ Date:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order #
Paid By:_
Account #:
Amount:$
ived By:_
Invoice #:
Date:
Davie County, NC ITax Parcel Report Tuesday. January 31, 2017
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
WARNING: THIS IS NOT A SURVEY
Parcel Information
F100000066 Township:
4890799720 Municipality:
Clarksville
30897600 Census Tract: 37059-801
GRIGGS LONNIE GRAY Voting Precinct: CLARKSVILLE
2160 SHEFFIELD ROAD Planning Jurisdiction: Davie County
HARMONY Zoning Class: DAVIE COUNTY R-20
NC Zoning Overlay:
286349099 Voluntary Ag. District:
LOT 4 HILLTOP ESTATES Fire Response District:
0.91 Elementary School Zone:
Land Value:
Total Assessed Value:
4/1996 Middle School Zone:
001860514 Soil Types:
0008 Flood Zone:
122 Watershed Overlay:
Outbuilding & Extra
Freatures Value:
Total Market Value:
SHEFFIELD - CALAHALN
WILLIAM R DAVIE
NORTH DAVIE
PcC2,CeB2
DAVIE COUNTY
IM
l.I All data Is provided as Is without warranty or guarantee of any ldnd 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
NCor arising out of the use or Inability to use the GIS data provided by this website. -
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, tNC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002484
Billed To: Schult Housing Advantage
Reference Name:
Proposed Facility Residence
Tax PIN/EH #: 4891-80-3319.04SH
Subdivision Info: Lonnie Griggs Lot # 4
Location/Address: Sheffield Rd. -28634
Property Size: .08 acres
ATC Number: 3821
**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 H #People #Bedrooms Y #Baths .2
Dishwasher: X� Garbage Disposal: ❑ Washing Machine;X Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply (,s Design Wastewater Flow (GPD) 5�19d Site: New Repair ❑
System Specifications: Tank Size/d/)GAL. Pump Tank
Other:
Required Site Modifications/Conditions:
GAL. Trench Width S_(" Rock Depth � Linear Ft. 7W
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISER(S) IF 6 " 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:
Ak�
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 #: 990002484
Billed To: Schult Housing Advantage
Reference Name:
Proposed Facility Residence
ATC Number: 3821
tZIg���`�
Tax PIN/EH #: 4891-80-3319.04SH
Subdivision Info: Lonnie Griggs Lot # 4
Location/Address: Sheffield Rd. -28634
Property Size: .08 acres
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 WASTEWATER CONSTRRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: ice/ A �/ 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.
Septic System Installed By: Z17
T
Environmental Health Specialist's Signature: Date:�2
DCHD 05/99 (Revised)
APPLICATION FOR SITE EVALUATI ON/IM PROVU-1 ENT PERMIT D C O
Davie County Health Department
Environmental Hea/tly Section JUL 6 ,�
P.O. Box 848/210 Hospital Street ZVI
Mocksville, NC 27028
(336) 751-8760 p,+w
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***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED'
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name toSt-.4\ +�
be Billed (^S �A +,� /'�` 0 n o, I/Nv�or('.fL. Contact Person
Mailing Address % 63 t S ' /- Na,r�J' Cross Home Phone � I
City/State/ZIP Nw•,—teTsN, f 1R- N C .7,7-0-76 Business Phone %0'T - 0 Z-
2.
-2. Name on Permit/ATC if Different than Above 17-q 1-4 &J C'.�' q'r
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC Both
4. System to service: X House ❑ Mobile Home ❑ Business ❑ Industry LI Other
5. If Residence: # People # Bedrooms !4 # Bathrooms
",*/-
_
y() Dishwasher 13 Garbage Disposal )K Washing Machine 11 Basemmeen'it/P-lumbing II 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: County/City ❑ Well LI Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes >�No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETCTHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
"ge%l4to33l 5
Property Dimensions:0.8 0.trTQ-s
Tax Office PIN: #�� d ' —3 3 / 9. O
Property Address: Road Name�zzj -
City/zip 2� t. 3 `/
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
If in a Subdivision provide information, as follows:
Name: %i l (fcs S Cz �t— _�_ Q CIA
Section: Block: Lot: Date Property Flagged: z + d -/
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 /6 o 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).
r
Revised DCHD (07/99)
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No. ZY
Invoice No. Z
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SIRG INC
'CATION FOR SITE EV4LUATI0N/I11N(IOVGHE`T PERMIT & AX
Davie County Health Department
Environmental Health SeCtlOn
P.O. Box 848/210 Hospital Street
Mocksvilla, NC 27029
(336)751-9760 7CIIv�p/
(3 34)-7 0 Oto
PAGE 01
aeI \t J � IS APPLICATION CA MOT B$ PROM55$D UNLESS ALL THE REQUIRED
0 9 PROVIDS0. Refer totheINFORMATION BULLETIN for instructions.
o to h• Billed L.t:nn. C �? _ Content Person L o -9-
Mailtn2 Addreas? t yl7 _ . Q ', a td (Zd Home Phoria 3310. 4
•�cler/Seat./zfr k� ry,�,. /u t, a:Business Phone 33(p. L-ca�-�
):ams on Perait/ATC if Dlffetantttthee. Above
�llnp Addreas _ City/State/Zip
�.X. Application Port—VoSita Evaluation ❑ Improvement:Permit/ATC ED Both
�--r @
system to service, ' }{oust ❑ Mobile Home ❑ Business ❑ Industry ❑ other
Type system requested, CRo Conventional Q conventional moditiod ❑ innovative
//
,I.ff Residence: #Deopl , _ r Bedrooms 3 n Sathroome `? 2
..�AODishwasher C7Carbags Disposal E7Wasbing Machine ❑ilasenent/PSui ing ❑Dasament/Ko Plumbing
7. It business/Industry /other: verify typo
I CortmTodss
9 People _. R sinke
0 ihower• a urinals , N Water Coolera
IF FOODSERVIC$t M Seats Estimated Water Usage (gallons per day)
rype of water supply- ❑ County/City & well O community
ti-. '30 you anticipate additions or expansions of (lie flicillty this sysicnt Is lntetttlM to terve? ❑ Yes M-Noi
!r ycs, what type?
"`•lAtP .1NT"" CLILsNT,MU OMPLL'TB111C REQU/KCD PItOPER1'Y 1Nl:412MA'I'ION ItIiQUL'S'('I;I)
net,ow. T S PL MUSrRRS(/QM/TTCD by tbt Nicht will, T1115 APPLICATION.
L--fl—operty Diutcn "ons: ��'X .O C DtttL"CT10NS (rru�n Miodcrt iitc} to fltflPYlt't'1':
i s office PIN: I]_y CL
�)yylerty Address: Road Namez�`i o ShQS�.e 1 d Q c� V_4it
City/zip 4 rf\% tJc oZglo 3 `� 'p 1���' ��awx,�Or,. 88Q/4
If in a Subdivision provide infornlatiot•, Rs follows:
a - �►`�'�.�A,t�Qltp,(, 1
V
5cclioD: Bloc):: Lo(:iom corners tingged: ���j pia.
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This is to coilO, that file inrornlatlon proAded is correct to Ole best of illy knoviedgc. I ulldertrtand that HHy I)CI'lull(s)
h6ucd hereafter are subject to suspension or revocation, if Clic site plats or Intended use change, or if (lie iul'oruclUon
submitted in this appllcat(utl is falsified or changed, I, also, unJersmnd /hat/ci,r iupoi�flbldjorn/!c/rr,�srs Incrn-,•c•d pu»,
ilris nppliroiirai, I, horeby, rive consent to the Authorized Representative of the Davie County licalth Dcpnrttncrtt
to enter upon nbove deycribcd property Ic :otcd In Davle County and owned by .
to cundw0 all tcsibig procedures us necest try to determine tine site suitability.
APPLICANT INFORMATION
Account #: 990003250
Billed To: Lonnie Griggs
Reference Name:
Proposed Facility: Residence
Water Supply: On -Site Well
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPERTY INFORMATION
Tax PIN/EH #: 4891-80-3319.04
Subdivision Info:
Location/Address: 2140 Sheffield Rd. -28634
Property Size: 135'x 330' Date Evaluated: lj - Dy
Community
Evaluation By: Auger Boring Pit l/
Public i
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
L
Sloe %
HORIZON I DEPTH
'
Texture groupL,
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group�i
Consistence
/
y
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:
i
LONG-TERM ACCEPTANCE RATE: `
REMARKS:
LEGEND
Landscape Position
EVALUATION BY:
OTHER(S) PRESENT:
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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A 1E C9,] N7 HEA THi DtPa� Th IT
Environmental Health Section
P. 0. Box 848/210 Hospital Street
Courier 09-40-06
Mocksville, NC 27028
(336)751 8760
June 11, 2004
Lonnie Griggs
2140 Sheffield Road
Harmony, NC 28634
Re: Site Evaluation/ Sheffield Road —four lots
Tax Office PIN: #4891-80-3319
Dear Client(s):
As requested, a representative from this office visited the aforementioned site on,
June 10, 2004 Based upon the information provided on the Application for Site
Evaluation and after an evaluation was completed on the sites, the sites were found to be
provisionally suitable for the installation of an on-site sewage system.
Before an Improvement Permit/Authorization to Construct can be issued the appropriate
application must be filled out and the house/mobile home location staked off.
If you have any questions, please feel free to contact this office.
Sincerely,
A4ve &. ik4aA -
Robert B. Hall, Jr., R.S.
Environmental Health Specialist
RBH/dlf
Enclosure(s)