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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. Pp f1t P % dej J-Gcl.r u Gr ct � e -} h.e, a r .r.,. -� � 5-cP�i c i N,. �.si to -� l` -r c (^ « k •� d 1 �a �c I X -(M G lx is r'1 -e-c4a bt Ael -/C, i n51CO sy. C1 Pwn4 r"K15 be s a CCA 11, \ � 1 n4 i &A �. 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 Davie County, NC - GIS/Mapping System s9. Click Here To Start Over m. Al k Active Layer. ❑Use iVap Tips �0 t% PARCELS (Map Tips Available) v Page 1 of 1 Quick Search: (County ID or Owner Ni M. Addre 0 o51ft http://maps.co. davie.nc.usIGoMapslmap/Index.cfm?mainmapservice=gomaps&CFID=412... 3/16/2009 06/03/2004 07:49 33667 -� OI0� t n� N�p"A 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 �1�7 Cnt HD' t1 ***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 0 U I , Ui, 64 ia.;(i rA'i 06-/:Z5/2004 16:44 336766F I 1 101 IM till It IA Ad -11 N.ILR CKS 2 V.4 MON U. boT• .3 'I t , 3C3 A -A DWA t 0 .660 ACRES L0002 FRISBY AEROSP PAGE Pj! Ift.9 CDRN C33 u) r--151 Lh Z,�a ' N ENY IRON Na PLACM NAIL IN FENCE "C0111,11 g, NEW IRON N Ew Ira a U R u Q t L imll— T FENCE CORNER Ift.9 CDRN C33 u) r--151 Lh Z,�a ' N ENY IRON Na PLACM NAIL IN FENCE "C0111,11 g, NEW IRON N Ew Ira a U R u Q t L imll— 106/.03/2004 07:49 � t' A Vv �D �?, 3 DZI 73884 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. '.r 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) ■■ ■■ ■■ ME ■■ ONE No No ■■■■M■M■M■■ ■EMEM■■M■M■ ■EM■■O■ME■■ ■EME■EMEMM■ ■MME■■■M■ ■EM■■E■E■ ■M■MME■EM■■ ■■■E■EMEME■ ■■MME■EMM■■ ■■■ME■EMEM■ ■■MEMEMMEM■ ■EM■EME■■E■ ■M■■■EMM■ ■■M■EMEM■ ■MM■MEMEMM■ ■EM■■EMEM■■ ■MEM■MOMM■■ ■■EMEMME■■■ ■E■EME■MM■■ ■E■EMEM■M■■ ■■■MEMO■■■■ ■MMM■■■■■■■ ■■MM■■■MEM■ ■■■■MMOMME■ ■MEM■E■■M■■ ■E■■■E■■EM■ ■OM■■EMEM■■ ■■■■■MEMMM■ ■■■■■■■■E■■■■■■■■■■E■EE■E■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■ ■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■ONE ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ no MEN■■ SEEMS ■MEM■ ■O■■ MEN ■O■■ NONE ■■N■ ■O■■ NONE ■O■■ NEE ■■■■■MME■EME■ ■■■EMMEEMEME■ ■■■■■ME■EMEM■ ■E■E■MEMEMEM■ ■■MEMME■MEME■ ■MMMMMMMMMMM■ ■■■■MEMEMEME■ ■■MEMEMMEMME■ ■■■■■MEMEMME■ ■MMEMMEMME■■■ ■■■■MEEMEMM■■ ■■■EM■MEME■■■ ■■■M■MEM■M■■■ ■E■MMEM■■■■■■ ■E■■M■MMEMO■■ ■E■■E■E■■■ME■ ■EMMEMMO■■E■■ ■E■■EM■■MEME■ ■E■■M■ ■E■■E■ ■EN■■■ ■ 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)