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123 Serenity Hills Trail Lot 11Davie Countv. NC Tax Pnrnai R annrt Monday. November 7. 2016 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: Land Value: Total Assessed Value: WA"11NU: '1'H1J 1, 1VU1 A NUKVEY Parcel Information B7010A0011 Township: Farmington 5863488958 Municipality: 8305140 Census Tract: 37059-802 TEARPOCK VINCE , Voting Precinct: FARMINGTON 158 NORTH FORKE DRIVE Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY R -A NC Zoning Overlay: DAVIE COUNTY QD 27006 Voluntary Ag. District: No LOT 11 RIVER BEND HILLS Fire Response District: FARMINGTON 5.65 Elementary School Zone: PINEBROOK 6/2015 Middle School Zone: NORTH DAVIE 009920515 Soil Types: WeB,RnC,PcC2,RnD 0006 Flood Zone: 162 Watershed Overlay: DAVIE COUNTY 0.00 Outbuilding & Extra 0.00 Freatures Value: 106410.00 Total Market Value: 106410.00 106410.00 101 1�T ll data Is provided as Is without warranty or guarantee of any kind 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 l� C or arising out of the use or Inability to use the GIS data provided by this website. • Well Certification of Completion For office use Only Davie County Health Department *CDP File Number 196950 210 Hospital Street PIN Number P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336.753-1680 Tax Lot #: Tax Block #: Evaluated For. WELL Property Owner. Vince Tearpock Applicant: Henderson Custom Homes Address: 123 Serenity Hills Trail Address: 1368 Meadowgate Lane City Advance City: Lewisville State2ip: NC 27006 State/Zip: NC 27023 Phone #: Phone #: Directions Drilling Contractor 1-40 East exit Hwy 801, left to Yadkin Valley Rd on ,M,A,T,T,H,E,W, ,8,R,0,W,N, , Right. go to Sand Pit, then Serenity Hills Driller Registration 13,0,3,6, .. , , , , , , , , , , ,_, Date Drilled 0 6/ 2 9/ 2 0 1 6 Replacement Well [] Yes No Total Depth 5 0 2 Ft Use of Well SINGLE FAMILY Static Water 4 0 Ft Yield 8 gpm Water Zone 1) .1 4 0 Ft 2) 3 7 0 Ft 3) Ft 4) Ft Chlorination Type: GRANULAR Amount: A L J i Casing: Depth: 1 0 8 Ft Thickness 0 . 1 8 8 In. Diameter 6 In Top of Casing 1 2 In. Material GALVANIZED STEEL Grout Depth Material Method BENTONrrE PUMP From. ;1 0 . To 3 FL BENTONITE PUMP From ` 3 . To. Ft. From . To. FL *Llner Date:O 8/ 1 7/ 2 0 1 6From , To , . FL well riller Signature 2140 -Nations, Robert 'Signature Date;O 8/ 1 7/ x 0 1 6 Grout Inspected by. EHSK Issued by. 2140 -Nations, Robert ion: Latitude 36o3ot Longitude: Enclosure Enclosure Floor Access Port Vent Bib Cock Back Flow 802823 [] Yes [] Yes Yes Yes Yes Yes 'Date: 08/ 1 7/ 2 0 1 6 No Water Sample / Yes [:]No @Hand Drawing Olmport Drawing Tee bet) R]Yes nNo L;omme Suction Line Yes nNo No Temporary nYes No 0 No Well I.D. Plate jjYes nNo N ° ❑[] Pump I.D. Plate ]Yes nNo Robert N o EH S: 2140 - Nations. Pq No issue Date: .0.8./.1.7./.2.0J.5. No Water Sample / Yes [:]No @Hand Drawing Olmport Drawing WELL CERTIFICATE OF COMPLETION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Well Certificate of Completion CDP File Number: 196950 County File Number: Date: Q Inch Scale: OBlock QN/A — ft j j j J j L-U E II 11 it ij 1 f } _ , I t i WELL CERTIFICATE OF COMPLETION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 196950 County File Number: Date: % k__,_, /. Click below to import an image from an external location: Drawing Type: Well Certificate of Completion WELL CONSTRUCTION RECORD This form can be used farsinglq or multiple wells 1. Well Contractor Information: Nell ContractorName 3©366 NC Nell Contractor CertificatiaaNuniber adkin Well Companv. inc Company Name / q 2. Well Construction Permit 0. t0 (• �0 List all applicable u.ell constructionpzrmlis (Le. County, State, Parlance, etc.) 3. Wcll Use (cbecicwell use): 17Agricultural DMuaicipal/Public DGeotherma} (Pleating/CooTing Supply) kkj�,esidential Water Supply (single) DIndustrial/Commercial ❑Residential Water Supply (shared) Non -'Water Supply Wcll: ❑AquiferRecharge ❑GrouadwaterRemediation ❑Aquifer Storage and Recovery ❑Salinity Barrier ❑Aquifer Test ❑StormwaterDrainage OExperimental TechnoloMr ❑Subsidence Control ❑Geothermal (Closed Loop) ❑Tracer ❑Geothermal (Heating/CoolingRetum) 001her(explain under U21 Remarks) 4. Date Well(s)Completed: 0- weilm—, Ay�&--5- 52. WeIlLocqtiow. 5-52.WeIlLOCation: Phone number 3 Facility/Owner Name Facultypqa ra*k PhysicAAddtess, City, and Zip PR y6 q-, County Parcel Identification No. (M) 5b. iratitude and Lonagitade in dearces/minutes/seconds or decimal degrees: (irwell field, one lat/long is sufficient) �4 ?, 1 N 6. Is (are) the well(s): Permanent or ❑Temporary 7. Is this A repair to an esisting well: ❑Xes or *0 IffUS is a repair, fill out knorrnlretl corrshuctiorr information and explain the nature ofthe rzpair render i921 rema7kr section or on the back of this form. S. Number of wells constructed: For an&tDlainjectionornon-wafersrrppllpIvallsONLY iththesarneconsirriction,youcan subntlt oneform. 1 9. Total welldeplb below land surface: -To a (ft.) For mulrlple wells list all depilas ifdlperern (example-3(ar 00' and 2(q�7001 ' RECEIVED FarIutemalUsaONLY- JUL 19 2016 U rt a y Ix !4 4 7o ft' 13 7.2 ft ;_ i. OUTER CASING for multi-casedrvells OR) LOai I TOMAI= TE ft ft. in. INNER CASING OR TUBING ea thermal cl LOM TO TE ft d )1"3LjWM='ER ft fin, SCREEN ObI 1 TO DLf1j=R SLOTSIZ ft fn ft. in. ft 3 ft ft do ft. fL ft 5/GRAVEL PAC TO ft ft ft ft 0 ft10 0 f.. 01 J Woo ft ,?.• ft .S- � G e o[ v s ft & ft. ft ft ft ft I S 22. Certification: Signature ofCerti eMell Contractor Data Ey sigon a rhfs form, I hereby cert that the wells) was (rere) constructed in accordance wiUh 15ANCAC 03C.0100 or 1SANCAC 02C.0200 Well Construction .7tandards and rhat a copy ofthis record has been provided to the well owner. 23. Site diad am or additional well details: You may use the bacl, of this page to provide additional -vveIl site details or well construction details. You may also attach additional pages ifnecessary. SUBMITTAL INSTUCTIONS 24a. For All 1TrelIs: Submit this form tivithin 30 days of completion of well construction to the following: 10. Static lI'ater level beloN top of casing / (/ (ft) Division of Water Quality, Information ProeessfngTJnit, Ifirarerlevel is above cani_, use "1^ 1617 DWI Service Center•,Raleiglr, NC 27699-1617 11. Borehole diameter: Bit Of i_l7 �4 0 �� 2sb. For Inieetion 1Vells: In addition to sending the form to the address in 2da above, also submit a copy of this form within 30 days of completion of well 12. Weil construction mefnod: - ko ta't"•_V construction to the following (i.e. auger, rotary, cable, direerpush• etc.) Division oftiVater Quality, underground Injection Control Program, FOR WATER SUPPLY MULLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636 13a. Yield (gym) _ Method oltest: °tif 24G For'Water StimAy & Iniection Wells- In addition to sending the form to q the address(es) above, dlso submit one copy of this form within 30 days of 13b. Disinfection type: HTH Amount: _y�J,, Clips completion of tivell construction to the county health department of the county where constructed �13az� Form MV -1 North Carolina Department ofEnvironment :urd Natural Resources -Division ofWater Quality Revised ]an. 2013 ZA Date Site Visited: _; 2. 2- /G By - (/®j Builders Name:,//g, �a�sj' Ooh,- f,7v�Wners Name: ll,CCgkpaGAC Address: c S $f�` t'ar� .got, Address • �' 8` !?? etc , Adc'ryg Phone Number: Phone: y Cell Number: e A fu iklT61i Well Construction Permit Davie County Health Department t¢'�4 Ty 210 Hospital Street t� P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Property Owner: Vince Tearpock Address: 158 N Fork Dr City: Advance State/Zip: NC 27006 Phone M rFor Office Use OnIV *CDP File Number 196950 PIN Number: Tax Lot #: Tax Block #: Evaluated For: WELL — VLKMI I VALIU UN I IL: 9/3U/ZOZO Applicant: Henderson Custom Homes Address: 1368 Meadowgate Lane City: Lewisville State2ip: NC 27023 Phone #: Address/Road M Subdivision: River Bend Hills Phase: Lot: 11 123 Serenity Hills Trail Advance NC 27006 Latitude Longitude , , Site Address: 123 Serenity Hills Trail *Proposed use of Well: If Other: Directions Directions: 1-40 East exit Hwy 801, left to Yadkin Valley Rd on Right. go to Sand Pit, then Serenity Hills Well Contractor Information Drilling Contractor Driller Registration , I I I I I I I I 1 1 1 1 1 1 1 1 1 1 1 1 1 1, , 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1, Permit Conditions *Permit Conditions chmcfels Remelting 4000 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 may be revoked at any time for failure to comply with enasting 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 .14 *Date of Issue; 0 l 9 , / , 3 l 0 , /Lal 0 l 1 l 5 , Authorized State (& Hand Drawing O Import Drawing Owner/Applicant Signature: .'Site Plan/Drawing attached.** Page 1 of 2 WELL CONSTRUCTION PERMIT 196950 Davie County Health Department CDP File Number: 210 Hospital Street s1ya P.O. Box 848 County File Number: Mocksville NC 27028 Date: 0,9 /,310 /.a,0,1,5 O Inch Drawing Type: Well Permit Scale: O Block , O N/A J%A �\ L :. .. zt_-, . ..fi. Ci Page 2 of 2 P1 P3 WELL CONSTRUCTION PERMIT Davie County Health Department 210 Hospital Street P_O. Box 848 Mocksville NC 27028 CDP File Number: 196950 County File Number: Date:.0,9.1.3,0./.a,0,1,5. Drawing Type: Well Permit Page 2 of 2 P1 P2 DAVIE COUNTY WELL CERTIFICATE OF%COMPLETION CHECKLIST Applicant: n C'e File #: �5�d Site Address: ) :50r-er7 IK % S 7/ Subdivision: Lot: Permit Type: New Well Well Repair Well Abandonment Other Facility Type: Residential mood Service Church Commercial Other nitial Inspection Were Setbacks Maintained? Yes No What is the Grout Depth? 3 ft. If No, Explain: What is the Grout Thickness? 2 in. What is the Type of Well? o..l (.p Was a Well Screen Installed? What is the Casing Type? j!�2 G f vas /` Type of Drilling Fluids Used: C��1 What is the Casing Depth? 0\-\C)s ft. Well Grout Inspection Date: 6, - D, What is the Well Diameter? (,r� t in. GPS Coordinates: What is the Well Depth? O '),ft. EHS ID: Well Head Inspection Is There an Access Port? 1 e Is There a Vent? Is There a 4 Pad? Is There a Hose Bibb? What is the Casing Height? t �--Is There any Grout Settlement? _ What is the Static Water Level? k a' ft. ✓ What is the Yield? GPM Is the Well Contractor ID Plate Comj�lete? Is the Pump Installer ID Plate Complete? Contractor Name: �`� k ` �I Pump Installer Name: Contractor Certification #: Date Installed: Depth of Well: �C% �. Depth of Pump Intake: Casing Depth and Inside Diameter: Pump Horsepower Rating: Screened Intervals: Opening for Piping & Wiring >_ 12": Packing Intervals (Sand Packed Wells): Yield in GPM or GPM/ft.-dd: Static Water Level and Date Measured: �{ Date Well Completed: ts-- 2 � % (o Well Head Inspection Date: k2 EHS ID: ALl- Construction Completed Date: /9 ',� _ S — l Co Contractor Reports Received Date: Sample Date: 0-(-7-( Results Mailed Date: Certificate of Completion Date: Authorized Agent: Davie COUNTY 210 Hospital Street P.O. Box 848 Mocksville NC 27028 TEL: 336-753-6780 FAx:336-753-1680 Request ID: 67732 REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT REQUEST DATE: 07/28/2016 TAKEN BY: SECTION: N/A TYPE: PROPERTY NUMBER: 196950 ASSIGNED TO: Mitchell, Brittany ESTABLISHMENT NUMBER: PERSON OR PREMISES TO SEE: OWNER: Vince Tearpock Vince Tearpock 158 N Fork Dr 123 Serenity Hills Trail Advance , 27006 Advance NC, 27006 REQUESTED BY: Homeowner HOME: WORK: Cell: Additional Information: CONDITION REPORTED: Request new well samples COMMENTS: RECORD OF INVESTIGATION Next Inspection Date: Status of Complaint: OPEN Resolved Date: Complaintant Contacted: NO Property Owner: Vince Tearpock Address: 158 N Fork Dr City: Advance State/Zip: NC 27006 Phone M idress/Road M 123 Serenity Hills Trail For Office Use Only *CDP File Number 196950 PIN Number: Tax Lot M Tax Block M Evaluated For: WELL t'tKMI I VHLIU UN I IL: U/SU/LULU Applicant: Henderson Custom Homes Address: 1368 Meadowgate Lane City: Lewisville State/Zip: NC 27023 Phone M Property Location & Site Information Advance NC 27006 Latitude Longitude Site Address: 123 Serenity Hills Trail Subdivision: River Bend Hills Phase: *Proposed use of Well: If Other: Lot: 11 Directions Directions: 1-40 East exit Hwy 801, left to Yadkin Valley Rd on Right. go to Sand Pit, then Serenity Hills Well Contractor Information 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 may be revoked at any time for failure to comply with 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, Robe *Date of Issue; 0191/13101/,a.0.1.5, Authorized State ® Hand Drawing O Import Drawing Owner/Applicant Signature: **Site Plan/Drawing attached.** Page 1 of 2 Chep do $ Remaining 4000 Well Construction Pgrmit Davie County Health' Department *moo -� 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Property Owner: Vince Tearpock Address: 158 N Fork Dr City: Advance State/Zip: NC 27006 Phone M idress/Road M 123 Serenity Hills Trail For Office Use Only *CDP File Number 196950 PIN Number: Tax Lot M Tax Block M Evaluated For: WELL t'tKMI I VHLIU UN I IL: U/SU/LULU Applicant: Henderson Custom Homes Address: 1368 Meadowgate Lane City: Lewisville State/Zip: NC 27023 Phone M Property Location & Site Information Advance NC 27006 Latitude Longitude Site Address: 123 Serenity Hills Trail Subdivision: River Bend Hills Phase: *Proposed use of Well: If Other: Lot: 11 Directions Directions: 1-40 East exit Hwy 801, left to Yadkin Valley Rd on Right. go to Sand Pit, then Serenity Hills Well Contractor Information 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 may be revoked at any time for failure to comply with 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, Robe *Date of Issue; 0191/13101/,a.0.1.5, Authorized State ® Hand Drawing O Import Drawing Owner/Applicant Signature: **Site Plan/Drawing attached.** Page 1 of 2 Chep do $ Remaining 4000 WELL CONSTRUCTION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP? File Number: 196950 County File Number: Date: 09 /_30/.2015 O Inch Page 2 of 2 P1 P3 i • OPERATION PERMIT fes. Davie County Health Department T 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Henderson Custom Homes, Inc Address: 1368 Meadow Chase Dr City: Lewisville, State0l): NC 27023 Phone #: (336) 399-2166 Address/Road #: 123 Serenity Hills Trail Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: *Water Supply: NEW WELL *IP Issued by. *CA issued by: 2140 - Nations, Robert Design Flow: 4 8 0 Soil Application Rate: 0 - a Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: *CDP File Number 196950-1 County ID Number. Evaluated For. NEW � Township: �roperty owner. Henderson Custom Homes, Inc Address: 1368 Meadow Chase Dr City: Lewisville, State/Zip, NC 27023 � Phone #: (336) 399-2166 erty Location & Site Information Subdivision: River Bend Hills Phase: Lot: 11 Directions 140 East exit Hwy 801, left to Yadkin Valley Rd on Right. go to Sand Pit, then Serenity Hills *System ClassifiicatantDescription: TYPE II A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) SaproliteSystem? ()Yes QNo *Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required? QYes (j)No *Pre Treatment: Drain ti 2 4 0 0 Sq. ft. 6 6 0 0 ft. 9 Inches O.C. 2Feet O.C. 3 Inches )Feet inches Minimum Trench Depth: 3 6 Minimum Soil Cover. a 4 Maximum Trench Depth: 3 6 Maximum Soil Cover: a 4 *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Frank Transou Certification #: 2711 *EH S: 2140 -Nations. Robert Date: 0 6/ 0 9/ 2 0 2 6 Inches Inches Approval Status Inches ® Approved 0 Disapproved Inches CDP File Number 196950 -1 County ID Number: Manufacturer Shoaf STB: 960 Gallons: 1000 septic TanK Lat. Date: 03/ l a/ a 0 1 6 *Filter Brand: POLYLOK PL -122 With Pipe Adapter ST Marker: ❑ Yes El No Reinforced Tank: ❑ Yes E No 1 Piece Tank: ❑ Yes B No Manufacturer. PT: Gallons: O Long: Installer.Frank iransou Certification #: 2711 *EH S: 2140 - Nations. Robert N Date: 0 6/ 0 9/ 2 0 1 6 Approval Status ® Approved ❑ Disapproved Pump Tank Date: / / RiserSealed ❑ Yes ❑ No RiserHeight: ❑ Yes ❑ No (Min.6 in.) Reinforced Tank: ❑ Yes ❑ No Piece Tank: ❑ ,\., Yes ❑ No / Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes ❑ No Installer: Certification #: *EH S: Date: Approval Status. ❑Approved ❑ Disapproved Supply trine Installer. Certification #: *EH S: Date: Approval Status ❑Approved ❑ Disapproved Pump Type: Installer: / Dosing Volume: - Gal Certification #: Draw Down: Inches *EHS: *Chan: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ NO Approval Status , PVC unions ❑Yes ❑ No ❑ Approved ❑ Disapproved Vent Hole ❑ Yes ❑ No Anti -siphon Hole ❑ Yes 0 No CDP File Number 196950 :1 Electric Eau%Dment County ID Number: N EMA 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 *EH S: Pump M anually 0 perable ❑ Yes ❑ No *Activation Method: Date: Alarm Audible C3Yes ElN o Approval Status Approved ❑ Disapproved Alarm Visible ❑ Yes ❑ No 2140 • Nations, Robert *Operation Permit completed by: JJJ� Authorized State Agent -// Date of Issue: 0 6/ 0 9/ 2 0 1 6 Owner/Applicant Signature: 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 .1900 et. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE 11 A. sewage septic system. Rule .1961 requires that a Type TYPE 11 A septic system meet the following criteria: Minimum System Review ByThe Local Health Department: NIA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: NIA Reporting Frequency By Certified Operator: NIA Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywith a certified operator or a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora homelbusiness owner must maintain a valid contract with a public management entitywith 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. GHand Drawing Olmport Drawing **Site Plan/[drawing attached.** OPERATION PEftMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP `File Number: 196950-1 County File Number: 27028 Date: Olnch Scale: OBlock ON/A s i ! r� __ cJ d f i E I i � I I ✓ Y i , ! ; , ! x , v rr_ t tS( , r I f z 1 CDP File Number 196950-1 ' County ID Number. Cj Open Pump System Sheet Repair System Required:@Yes ONO ONo, but has Available Space epair System Trench Spacing: 9 Inches O. . *Site Classification: Provisionally Suitable — Feet O.C. Trench Width: 0 Inches Design Flow: 4 8 0 _ ` 3 .@ Feet Soil Application Rate: 0 a Aggregate Depth: inches *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches *Proposed System: 25% REDUCTION Maximum Trench Depth: 3 6 Inches Nilrification Field a 4 0 Sq. ft. No. Drain Lines 5 Maximum Soil Cover: *Distribution Type: a 4 Inches GRAVITY - PARALLEL (eq.d-box) Total Trench Length: 6 0 0 ft \ Pump Required: Oyes Pre Treatment: ONSF (j)No OMay Be Required OTS -1 OTS -II *Site Modifications No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department. *Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees 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 be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and maybe issued at the sametime 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 maybe 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: W / / *Issued By: 2140 - Nations, Robert 4 42 Date of Issue:. 0 9 / 3 0 / 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 For Office Use Oniv *CDP File Number 196950-1 County ID Number: Evaluated For: NEW Township: MOCkSVIlle NC 27028 FI=KMI I VALID UN 1 IL: Phone: 336-753-6780 Fax: 336-753-1680 0 9/ 3 0/ a 0 a 0 Applicant: Henderson Custom Homes, Inc Address: 1368 Meadow Chase Dr City: Lewisville, StatetZip: NC 27023 Phone #: (336) 399-2166 Address/Road M 123 Serenity Hills Trail Advance NC 27006 Structure: SINGLE FAMILY # of Bedrooms: 4 # of People: "Water Supply: NEW WELL Property Owner: Henderson Custom Homes, Inc Address: 1368 Meadow Chase Dr City: Lewisville, State/Zip: NC 27023 Phone #: (336) 399-2166 Subdivision: River Bend Hills Phase: Lot: 11 Directions 1-40 East exit Hwy 801, left to Yadkin Valley Rd on Right. go to Sand Pit, then Serenity Hills Dnnn 1 nf'3 Trench Depth: a 4suitable Inches \Site Classification: ProvisionallyMinimum Saprolite System? OYes (bNo Minimum Soil Cover. 1 a Inches Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 - a 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) Septic Tank: 0 0 0 Gallons "Proposed System: 25% REDUCTION 1 -Piece: OYes QNo Pump Required: OYes @No OMay Be Required Nitrification Field a 4 0 0 Sq. ft, Pump lank: Gallons No. Drain Lines 5 1 -Piece: OYes QNo Total Trench Length: 6 0 0 GPM—vs— ft. TDH tt Trench Spacing:9 _ Inches O.C. Dosing Volume: Gallons @FeetO.C. Trench Width: 3 Inches g Feet — _ Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -II / Septic Tank InstallerGrade Level Required: OI Oil OIII OIV Dnnn 1 nf'3 CONSTRUCTION AUTHORIZATION Davie County Health Department ' 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization C om• -; tr 6z= -�- I i I/ Nil I I I r CDP File Number: 196950 -1 County File Number: Date: 09/30/2015 Q Inch Scale: tock = A. QN/A or t o ''" 0 W-! y CONSTRUC"r1ON AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: 196950 -1 County File Number. Date: _0 .g / 3 0/ 2 0 1 5 Click below to Import an image from an external location: Drawing Type: Construction Authorization 4 ay sou r APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION 1S PROVIDED. APPLICANT INFORMATION Name "_ eD t cfj t, s -r _^ 4v rr.`,S Contact Person r J Address (368 �d(,,.,� o.4cr L Home Phone City/State/ZIP �,Qwv�Sv�ll4 r x, �'70� '� Business Phone ?sae, -Zt (e Email �.tv� c��• sa. E,l,vaw2 [� �, , �`, c� .. Name on Permit if Different than Above Mailing Address l368 w`eA,G j a�.l a.. City/State/Zip Uwts-t4. NL 7-702-5 PROPERTY INFORMATION *Date House/Facility Corners Flagged NOTE: A survey plat or site plan must accompany this application. Included: Site Plan Plat (to scale) Owner's Name \ J t vtce 4- e_&,.- V c ct4_ Phone Number Owner's Address t S-9 no– &wL.,, City/State/Zip A-ei va a• 2-7o oL Property Address l'L3 $«•� 44,1�s 1),�.1 C►ry, Add,.,,r_ Lot Size S, o t.'7 Acr-" Irax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: DEVELOPMENT INFORMATION Permit Type: New Well Y— Well Repair Well Abandonment Other (specify) Facility Type: ResidentialV— Food Service Church Commercial Other Are There Any Septic Systems Currently On The Site? YES NO )C Do Do You Intend To Install A New Septic System On This Site? YES_ NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions, the specific location of the facility and any existing or future appurtenances, the location of any existing septic system, sewer lines, water lines, any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible. By signing this application, the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. Signed 7/30/09 --1 -1 Date Site Revisit Charge Date(s): Client Notification Date: EHS: Account # _ Invoice # I N W E S P.B. 6. PG. 185 ,0 P.B. 6, PG. 185 14$. 0' Et h 1, 5.067 AC. t N/F ROY W.• WALLACE D.B. 552, PG. 172 N/F ALEXANDER S. MCGUIRE D.Q. 454, PG. 88 PRELIMINARY PLAT FOR PERMITTING PURPOSES ONLY 4' t,lSs o2Qg5y� �� 8_719 3' TO C \.SbUDP HILLS HOA BEND P.B. 6. PG. 185 N/F DAVID M. HANES D.B. 561. PG. 716 INSET 1`=50' PROPOSED SITE PLAN OF LOT 11, RIVER BEND HILLS FARMINGTON TOWNSHIP, DAME COUNTY, NORTH CAROLINA PLAT OF SURVEY FOR HENDERSON CUSTON HOMES Whitt Land Surveying 839 WATSON AVENUE WINSTON—SALEM. NC 27103 DATE: SCALE: (336) 722-1444 06/04/15 1� = 100' MAP RECORDED IN BOOK 6 PAGE 185 APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT &: ATC A Davie County Environmental Health R,�CEjV ptl�/ P.O. Box 848/2]0 Hospital Street L+'D C/ Mocksville, NC 27028 Date; ��- Data is (336)753-6780/ Fax (336)753-1680-'--/���� nation For: Site Evaluation/Improvement Permit Authorization To Construct (ATC) Both Type of Application: New Systetn Repair to Existing System Expansion/Modification of Existing System or Facility *"*LV1P0RTAN'Y*** THIS APPLICATION CANn'OT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name CvskvoM k�vvr14_4 _tnc Contact Person-Ova'c Address M \ Home Phone '33 (e - - ti - Z I L 6 City/State/ZIPS p w -_s ALL- '7O L- ' Business Phone Email , *txr. - o l- Email: kA C.wv&.l Name on Permit/ATC if Different than Above Mailint; Address 1"2,(At ,ML.vaLa— e'.J u.._ City/State/Zip w vo fJ L o PROPERTY 1NrURMA LION "Date House/facility Uorners flagged NOTE: A survey plat or site plan must accompany this application. Included: Site Plan Plat(to scale) (Permit is valid for 60 ilonths with site plan, no expiration with complete plat.) Owner's Name 0 Nn C.e- -reAe rpoc1r_ Phone Number Owner's Address I N tv City/State/Zip .td ✓ ar. ec. 2-7 o o Property Addresses S e y e,vv tJ,,. t1n,%k S �. City mei tra.,ti eL Lot Size O to -2 h Circ S Tax P104 Subdivision Name(if applicable) 12cr-w IP�� JkLL- _Section/Lot# Ik Directions To Site: w a oLtc Lt. L,. ll1 r iq ad A-, Se..,k to.k- 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 X No Does the site contain jurisdictional wetlands? _Yes X'No Are there any easements or right -of -Hays on the site'? Yes'6_No Is the site subject to approval by another public agency? _Yes cc No Will wastewater other than domestic sewage be generated? Yes 1eNo IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms 4 # Bathrooms_ Garden Tub/Whirlpool Yes Basement: _Yes N Basement Plumbing: Yes No IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building b # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested:omentional Accepted Innovative Alternative .Other Water Supply Type: County/City Water )(New Well Existing Well Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? _- Yes Ifyes, what type'? ?,NO This is to certify that the information provided on this application is true and correct to the best of my knowledge. 1 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. l 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 t and am�ponsible for the proper identification and labeling of property lines and comers and locating and flagging h e/ ity location, proposed well location and the location of any other amenities. Site Revisit Charge ProNerty owners or owner's legal representative signature q�1 Date(s): ^ _ 1—t 5 Client Notification Date: Date EHS: Sign given . Yes ❑No Revised 11/06 Account # Iq4t� Invoice # S lee ' � Q PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC Davie County Health Department Environmental Health Section G 2 P.O. Box 848/210 Hospital Street Mocksville, NC 27028 vM PL�I (336) 751-8760 / /C N ** MBS *** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED I TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed S Contact Person _L� i C Mailing Address �� ����,1 �4��. C� Home Phone," ---,w%- ;:i-MC�1 City/State/ZIP CV.��..�VaS _ 1.� '`�p�� Business Phone _ 3JLe SC — b'l(}_�_ 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. 'Application For: IgSite Evaluation ❑ Improvement Permit/ATC ❑ Both 4. System to service:House ❑ Mobile Home 11 Business 13 Industry El Other 5. Type system requested7-N7:Conventional ❑ conventional modified 11 innovative 6. If Residence: # People_ # Bedrooms_ # Bathrooms ❑Dishwasher ❑Garbage Disposal ❑Washing Machine ❑Basement/Plumbing ❑Basement/No Plumbing 7. If Business/Industry /Other: verify type # People # Sinks # Commodes # Showers # Urinals # Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 8. Type of water supply: ❑ County/City X Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes X10 If yes, what type? 'IMPORTANT' CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions: -� atnx S Tax Office PIN: # Property Address: Road Name �g ` % \ City/Zipdiv t��g_- If in a Subdivision provide information, as follows: Name: X k\N S Section: Block: Lot:_ WRITE DIRECTIONS (from Mocksville) to PROPERTY: r � � Date home corners flagged: -0 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 suitabi ity. DATE SIGNATURE , THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed property lines and dimensions, structures, setbacks, and septic locations). Site Revisit Charge Date(s): Client Notification Date: EHS: Sign given Revised DCHD (05/03 Account No. 3 3 5 Invoice No. (o S DAME COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990003264 Billed To: Steve & Peggy Brackett Reference Name: Proposed t=aclity Residence ATC Number: 3798 Tax PIN/EH #: 5863-48-8958 Subdivision Info: Riverbend Hills Lot # 11 Location/Address: Serenity Hills Trail -27006 rroperiy size: o 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 CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: CERTIFICATE OF COMPLETION Date: **NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit has been installed in compliance with Article I 1 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: Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: May'21 04 04:53p PEGGY BRRCKETT 3369921978 tray 20.04 0E:24p davie counts enusheaith Jib 151 urnt. p.c APPUCA.TIDN FOR SITE LVALiiATION/IMPROYEMEN7 PERMIT a ATC Davis County Health Department Environmental Health Section P.O. Box 848/210 Hospital Street Mockavillse, NC 21028 (336)751-8760 •••IMPORTANT••• THIS APPLICATION CANUOT BE PROCESSED IUILESS ALL THE REQUIRED IMMRMATION IS PROVIMM- Refer to the INFORMATION BVLLBTIN for instructions. tel. sf— to be eitl.a ��e L� ';r �(:ttL7i i1 inJl/1%G fe .-'r' Cont,et Far— 21=111,01-,, ✓ Mailing Addres. P w �r�'O Y!�[ _ T ions Phon. ti �l i'2il�P a Citylstata/=zP n '.tt• • Nc y•.'.+�35 ae.in.n. Ph... // ✓ _� cit. Massa on Permit/ATC-it OL;ftar.nt than Above ...railing Address `-.Q ^ P etcy/ac.c./sip Application Parr (.LYSito Z'veluetion ❑ Improvement Permit/ATC Both 1 4S. srecem to servicer D`HOned ❑ Mobile Home ❑ Business ❑ Industry ❑ Other V's. Type system requested -ET Conventional D eone.ntional moditied ❑ Snnova:ive L� —6. If Residence: It People a Bedroomsf1�� 1 Bathrooms 7 ��LDiawuh.r s•PJOarbage Diept•sa1 +ouaableg Machine ' Basement/Plumblr.g 17Baaenont/No P1usMino 7. 1f Busi...sa/Industry /others verity type s People Is Sinks I rU,-*d.s P-:howors P Urinals P Hater Coolers IF FOODSERVICE: M seats latimated Hater Usage (gallon• per day) ,s. Trp. of ...tar .apply. 0 Courty/City ❑ well ❑ corrmmunity 7 P. Do you .nttcipat. addition• or expansions of the facility this system is intended tourve 0Yes W4. If yes, what type? •••l,HP tTR1YT••• CLIEN7 i MUSTC FLETETHE REQUIRED PROPERTY INFORMATION REQUESTED LOW Ri er a PLAT or S17E PLAN M TBESURAfl7TED by the client wit]; THIS APPLICATION. C---Proper(y Dimensions: L 9 L --WRITE DIRECTIONS (from M1loduviMe) to PROPERTY: ---T..[icr •as OfPIN. P -,5'96'3 4f 1 U Q C? -S U L,--troperty Address. Road Natrte SL'i in • ; •t �4 i s c CityrLip /4 UCl /t C L ; ,•1/G If in o Subdivision provide Informativa. as follows: Name: A' Il Pr tZend >J� • section: Block, ,t;"V, Lot: L.if:ffc home eornersflagged! p.2 .3 t- '- This is to co-tify that the information provided is correct to the best of my knowledge. I understand that any perinit(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. /, also, andersland droll am responsible jar all charges inunred ff one lhivaltldieariarr. 1, hereby, give consult to the Authorized Representative of the Davie County llcatth Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as nttrssary to derermine the site soitabtlNy. ' ,/DATE i �� / l� C OTGNATURE 1 � •� �1� u ,C_fl.U` THIS AREA MAYBE USED FOR DRr.%VING YOUR SITE PLAN (Include all of the following: IIsisting and proposed property tines and dimcnsi sts, structures, setbacks, and septic locations). SilaAcv[rll Charge t Datc(s): Client Notification Date: ��• Eas: Sign given / • a / Vv Account No_ L/ Reviser! DC119 (OSf83 �� a Invoice No. ny�0e It ^ \ 1/110 J' -U, �' , _JL'o t1V 0y, I � t L'/ c 1-i4s,-r— A', y,L-,ty �' / ti S ..- S r c� r 01;/17/04 10,:11 FAX 3367687988 GRAHAM AND BOLES Z002 ,Juri 16.04 04--10p davie county envhealth 33 1 B7 P.? DAVE COUMYhEALTH UR•PARThiW MIRONNIENTAL HEALTH SECTION P. 0. Box 648/210 Hospital Street Courier #09-40.06 Mocksville, NC 27028 Phone,#: (336)751.876U;._ - June 16, 2004 Mr. Steve Brackett 8831 Boylston Road Colfax, NC 27235 Re: Site evaluation/Rivert and Hills lot l 1 Tax office Pin # 5863.48-85 58 Dear Mr. Brackett: As requested, a representative of this office visited the aforementioned site on June 16, 2004. After an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Yetmit/Authorization to Construct can be issued the appropriate application must be filled ot.t 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., RS Environmental Health Specialist RBH: df DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Account #: 990003264 Tax PIN/EH #: 5863-48-8958 Billed To: Steve & Peggy Brackett Subdivision Info: Riverbend Hills Lot # 11 Reference Name: Location/Address: Serenity Hills Trail -27006 Proposed Facility Residence Property Size: 5 acres ATC Number: 3798 **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 #People_ #Bedrooms #Baths Dishwasher Garbage Disposal; Washing Machine: Basement w/Plumbing:� Basement/No Plumbing: 13 s Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑ Lot Size Type Water Supply Design Wastewater Flow (GPD) !Cl � Site: New -B— Repair ❑ System Specifications: Tank Sizez2aAL. Pump Tank Other: Required Site Modifications/Conditions: GAL. Trench Width,?'�/,' Rock Depth ,41 lel Linear Ft" 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 in.. or :00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.**** Al P` 1�� s '-so Environmental Health Specialist's Signature: DCHD 05/99 (Revised) Date: June 16, 2004 Mr. Steve Brackett 8831 Boylston Road Colfax, NC 27235 Re: Site evaluation/Riverbend Hills lot 11 Tax office Pin # 5863-48-8958 Dear Mr. Brackett: As requested, a representative of this office visited the aforementioned site on June 16, 2004. After an evaluation was completed on the site, the site was 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, A J41 - � & c,;; V. 4 ZZA. Robert B. Hall, Jr., RS Environmental Health Specialist Tax Lot 30 Tax Atop 3-7 n/f Nrginia C. wcitrer os 73 o Pc r3J Tax Lot 49 Tox Atop 8-7 n a C4 \ Tax Lot 49 a ror .Wap 8-7 F- e F- z 'P, � N SZ�oIf dJg 7j. 11 !.167 Acres +/- 10 Rivs Bend !ills P4 5 0 PG 123 ! 3/!" i;R Tie Line +cis: Nail Found S J9•45105' N in Povement 58.79' 'Q'«n and a�*.ncL tl I �vro ;" tno am. a ++ J11 .a.n er Wunry Paa Ce"e. ; / ,+na.rytM Ata. Ta ".rv. -I this a r a .Lil one e Crenite c, a this oac.. Monument .. / ..�' _ej -:is . q ar .rminq and .n �• / - tx m.nta r. lomimse a � � � 1 / Tran am no aa.rari.r,t a O �nmC.d urd+l 'aehanJ. . y / °tan, line Swv.t;.nq ra, 3/8 QR 4.3 wt :r nrantcdan. U61 Found JS -6v in Pavement '<�•1en :to.000- Ld Y �30-70' R I.N. Q NC- ry' •O - uiatnp 11410 menumertecn 1 y ^ / dae, not tamp .rtti IRS RS ` ;y RI racareed ..t rasa. S J4.20125' N 7 / t0' PRvet_ ,. h — Road"Y R/w Survey .For. rnonumenta4on uaed. S /92 � -- - - - - - �. } For: -' ��� °�zs N f Rei. Ps s o Pc tes Philip Anthony B LU LC£ND Tax tot 49 \ ut \ d/b/a CL RM - Itgnt�r-rar a - C.nt.r u". Tax Yap 8-7 Nob round a. O \v tv - Fd.ttiq Yee nP. ECv _ EdC "q. ei vn .m.nt n// David Al. Hants in Pavement "°" - ►... a Cu e `� Beauchamp Build2-n CU _Gil. M U- h.r Pal. DB 120 O PC 219 °- P" - P °Pr" Visag "" Sand Fit Road !I � C A - Cerraowd "ca.. P 0 Onrd girian.• M RCP wtar. - 9..d C --t. Pis. U _; t ,.nt �+ p PILZR BEND RILL. CUP - Camq.ua wtd ri�. - o..d oor S.R. 1453 �/� j Point in Pfet ..cok 6 UP - C—. "Ud plau. I. p9 - Ptet goa. ° 0 Pas. 193 q rear Flee. eaanaa - Gat r earn CL S.R. 145J 7.067 ACres ;/- -,head Illi - by CCCrt:inGte CC i 9w. -�oct o'� Cur1 1= ir-wM".IP CCI:HiY S p 100 0 t decfane tiigt on - !1 FSS- t•' = lec, F crmingtor. CGvie 100 200 300 ae surveyed the property ,hotrtE on Stone Land Surveying W plat: tt suRyl m: N GPHIC SCALE —FEET�-(( AS•MT Ow" boort Slone. ALS i-]• LAPPED: 'CC Scath .Van Str,gr. r. -o. •n. a �— GRS VacFsvil.. f1.C. 17C"<S E Li T 1 Cr! V1 Tie Line +cis: Nail Found S J9•45105' N in Povement 58.79' 'Q'«n and a�*.ncL tl I �vro ;" tno am. a ++ J11 .a.n er Wunry Paa Ce"e. ; / ,+na.rytM Ata. Ta ".rv. -I this a r a .Lil one e Crenite c, a this oac.. Monument .. / ..�' _ej -:is . q ar .rminq and .n �• / - tx m.nta r. lomimse a � � � 1 / Tran am no aa.rari.r,t a O �nmC.d urd+l 'aehanJ. . y / °tan, line Swv.t;.nq ra, 3/8 QR 4.3 wt :r nrantcdan. U61 Found JS -6v in Pavement '<�•1en :to.000- Ld Y �30-70' R I.N. Q NC- ry' •O - uiatnp 11410 menumertecn 1 y ^ / dae, not tamp .rtti IRS RS ` ;y RI racareed ..t rasa. S J4.20125' N 7 / t0' PRvet_ ,. h — Road"Y R/w Survey .For. rnonumenta4on uaed. S /92 � -- - - - - - �. } For: -' ��� °�zs N f Rei. Ps s o Pc tes Philip Anthony B LU LC£ND Tax tot 49 \ ut \ d/b/a CL RM - Itgnt�r-rar a - C.nt.r u". Tax Yap 8-7 Nob round a. O \v tv - Fd.ttiq Yee nP. ECv _ EdC "q. ei vn .m.nt n// David Al. Hants in Pavement "°" - ►... a Cu e `� Beauchamp Build2-n CU _Gil. M U- h.r Pal. DB 120 O PC 219 °- P" - P °Pr" Visag "" Sand Fit Road !I � C A - Cerraowd "ca.. P 0 Onrd girian.• M RCP wtar. - 9..d C --t. Pis. U _; t ,.nt �+ p PILZR BEND RILL. CUP - Camq.ua wtd ri�. - o..d oor S.R. 1453 �/� j Point in Pfet ..cok 6 UP - C—. "Ud plau. I. p9 - Ptet goa. ° 0 Pas. 193 q rear Flee. eaanaa - Gat r earn CL S.R. 145J 7.067 ACres ;/- -,head Illi - by CCCrt:inGte CC i 9w. -�oct o'� Cur1 1= ir-wM".IP CCI:HiY S p 100 0 t decfane tiigt on - !1 FSS- t•' = lec, F crmingtor. CGvie 100 200 300 ae surveyed the property ,hotrtE on Stone Land Surveying W plat: tt suRyl m: N GPHIC SCALE —FEET�-(( AS•MT Ow" boort Slone. ALS i-]• LAPPED: 'CC Scath .Van Str,gr. r. -o. •n. a �— GRS VacFsvil.. f1.C. 17C"<S E APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE - Davie County Health Department 0 �% Environmental Health Section P. O. Box 848011 DEC ' Mocksville, NC 27028 4 (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED-UNL-ESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed c._v lr ry\ Contact Person %O -V110 1-6"� T Mailing Address 3 d 1 a c S i a t Home Phone 19 to ` el r6 2 -7113 City/State/Zip T) Ue- r+LG 06 6 Business Phone S Go '7`1 k S^ 7 & 7 2. Name on Permit/ATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: S. If Residence: ❑ Dishwasher 6. If Business/Other: # Commodes If Foodservice: 7. Type of water supply: 9^ Site Evaluation 9'House ❑ Mobile Home # People ❑ Garbage Disposal Specify type City/State/Zip ❑ Improvement Permit & ATC ❑ Business ❑ Industry # Bedrooms ❑ Washing Machine ❑ Basement/Plumbing ❑ Both ❑ Other # Bathrooms ❑ Basement/No Plumbing # People # Sinks # Showers - # Urinals # Seats Estimated Water Usage (gallons per day) ❑ County/City U—Well # Water Coolers 8. Do you anticipate additions or expansions of the facility this system is intended to serve? If yes, what type? ❑ Community ❑ Yes ❑ No PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE I I SUBMITTED WITH TRIS APPLICATION. Property Dimensions: S• 6 7 2 64-v 1 WRITE DIRECTIONS (from 1 Mocksville) TO PROPERTY: Valle, Tax Office PIN: # S9 3 s e. s83 8' 1 �,'3z �ereniil�s Property Address: Road Namef1+CJ City/Zip .-,4c[ V Q-i/tCL P �� j , 1 If in Subdivision provide information, as follows: 1 <e r e- )i /V�, A5 - Name: `�) ! e r$ e n tji•� 1 r 1 of Section: Lot #: 1 1 — This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is 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 I'D c,. J %0 M . C"N e - S C s ��r 1+., �� to conduct all testing procedures as necessary to determine the site suitability. DATE ( I' I N A I,- SIGNATURE Revised DCHD (06-96) 11 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION_/ LOT_[- Soil/Site Evaluation APPLICANT'S NAMEf �� n/�S DATE EVALUATED�,��-� PROPOSED FACILITY PROPERTY SIZE v 6 SUBDIVISION "<),`vGr Z' 4Z tl%//f Water Supply: On -Site Well Community ROAD NAME Public Evaluation By: Auger Boring Pit c / /! Cut FACTORS 1 2 3 4 5 6 7 Landscape position L Slope % e, 7 '' HORIZON I DEPTH ti Texture group Consistence Structure Mineralogy HORIZON II DEPTH 77 Texture groupL' �► Consistence Structure !l < l Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION G / LONG-TERM ACCEPTANCE RATE i SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: , REMARKS: LEGEND DCHD (01-90) X Landscape Position EVALUATION BY: A4 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 ■ ■ ■ ■■■■■ ■MEM■ ■ENE■ ■E■E■ ■■■M■ ■■N■■ ■■N■■ ■M■M■ ■E■■■ ■;AMM■ ■ ARNE Elim■■ ■E■E■ ■■MM■ ■■ ■■■■■■■■■ ■NEEM■■■■ ■■■EME■■■ ■M■ME■■■■ ■■E■MM■■■ MEMEMMEME ■■MEN■MM■ ■E■■MEM■■ ■ ■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■ ■ ■ ■ ■■■■II■■■■111■'1��;><1■■■■■■■■■■■■■■■■ ■■■■II■■■■III!■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ E'. ■ ■ ■ ■■ ■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION Water Supply: On -Site Well Evaluation By: Auger Boring Community Pit PROPERTY INFORMATION Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position Sloe % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND Landscaae 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) RIM BEBID Huls Sheet 1 of � - --PkW and recorded in Plat Bode 6 page --- 162 on July 19, 19% at 3:20 P.M. \ M1A std"ear Od www o� anger vernods, war _ c w /r veer s+� dO GMM* wt 1R°�. i0WAft t Rd `A* "Mill • * .Own 6*ANWN w ft" Is Seek ALM11111L �--.3 so She tM I petera e0 edoftw ► 1 -*Aft ad M ti, - tAN fall So gome� tAA &Z OILER • awanSsd. Illinois ow oiwr •%MI* 4400I00 were ad .. aw 171Mdw 40 JULY ,r 1996 - Seel or Slwq jr slowpor, 2623 _ • 1 RagIMMIIn IIrwO� N,. 0 wpb �y�. l t e Nol•i PIM of to CWN* w1 aft •Rsew" safiy ad C. Rm DNR % w poesh"d Well ispIw. plosIAw oSwaN behm was as ei dw weft wiawls;sfi M some=orf go fb }wf • t«s/� LlL'1� >tlll a sw� R�� OF NeefifF MI eew.ilfie■ sleswe LQ -o gxc r*. .. iZ�,..e Parcel 2 T iMap A-7 G• Walker THIRD Book 77 POge 77 1 THIS PLAT WAS PREPARED TO SHOW A DMSION OF DAVID M. HANES PROPERTY, ALL TRACT SHOWN ARE 5.00 ACRES OR MORE AND DOES NOT CONSMM A4ki8QMS10N AS DEFINED BY THE DAME COUNTY "DN510N REGULATIONS. JESSE BOYCE,JR DIRECTO( OF SAN —D-- Rn The fN°Nlog sortlflset• ("M five MASE !✓046r % -Lb%tL s!f A3d: - 0—mAy AM aFFTIMTi IC1AL E W t OFFICER Slealm 1s s•rtlfles to be correct. Thio dy of le� Probate too geld. L• Hover) fiber's. Register' of D•oods by SAF -AW ISTANT •.4"Ap 1�6. 141 0� r0 d ��o y file.I Tfor regletretlow or 3 ^� s•elo" `' V`le—ii a" reser MA to Plot eeelt Few JIIE.AIL. Mowry here. Register N Deets F II" Fee Pwld ]�//-.•',-•� -- by iC. k 4..L.f�/ fi�.eeISTAM FLOW -� Total _Y � - e Parcel 2.01 �' a 4U �j S 04°28.05"W 97•Fto to. 3 I r94.;a Stephen A-7 I Tax Ma 2'02 t° o I N 9� �, 01• 572.58• X --x— r �r '--------- __ to NIP -x__ P W. Walker P A-7 "!'� 0 `�c�d�°� t 1�� D. B. 160. 618 r` t 7t 33• 482.01- Deed M. Walker N'e° a,` °.`\'vi„�', s, u�. I oa.--' '+ °' Book 179, P °•� "� N 'cero?_N '.1 _ j w N 06'05'30-W t s2. 72.92'. N 671 59 . EIP JEIP °9e 272 Iii i I „o,��•o'ti /� , `0o O '° N C 9 ,� •E ''tor s�a�-- _ .1..-- 0 '48'59'55"W !�?I.r i O W N N 35'44.45"W 74.E its• -�'�1 _ v1 l� ' �a5 h�T f W S 03°0910"W 293.89• ° �'� " ;P �� 4y� CFS 1 162.81' j r� * �s+E i t� ------ ---- 5i�' os� .i t>s -� ��� _ « v�ni h N ---s _ S 03 09' 10"W 549.75' e �� ,y�9 I-- _`vV S 48.47'25"W 123.89' '` N ► 'L C -tp Q "_�c� N -i 56 ,moi —_� fat°". �4� N + m Te !� ?J _. 00 24.4025'1Y 1t2.C1 , E,6 �'h� % � ��N t M / e1 X10 co tp (,+ J� is to9fA �T4T• �t�a• 6 NIP 1 `�. �I z S' Q -k N 14•t3'20"W 74.77 N �! 5 r - .S%9 Q3 U n _ Ifs? _ .%. T �j t!' l ' NIP 00 NIP 2X.89'--- - �g9 loc�C �� ` `�1�~ .$� 60' I� ° C ML PCINf 76.26' u! a 5��6 2Sly ------ ..� s ° o 6 A j �, , s. t' . N _ N Ct•50'1o"w.--_ ti/e o _ '10 POINf 42°20'40"E �-' LA OD '7.816 N J e��9�TlY �ti}� ,y V h O�Oe¢S�7f,.MF PCII�T 'S 50°59'45"E w 0.072 ACR O� f? O . 9� 35' d.iveway easement ��W O� �r0 S. f i 7$.87• N ACRES Z •'� a' g vj 4j� o00 124.22' 42°18'40"E - NIP ry ACRES NIP ,J f o ^i / �B9 124.22' V ^ tr^ 7 9 R �vp ? 4S� iia SToto G s N eh 7 S 6703 ,1 S"W 82.93 . 28.9r " J v A / 11 Qc�t� '' S y 4 )\2�°547 g0 C' c�s`�O\� NIP w'� AC,RES �, ES ,v1P 6.108 ACRE .;o�,' a.�z��',5,, 3 ss4s.w\ /�(.'0�j�'7 �,�o, 3 F \�ti \ R I S r io � p• 24 C, a 0 1 U `d3 0ose`r0 Og.55 NAv EIP OV 4 °f �°,Pol NIP / �� /w �'y ! 1G� i N N 08 33'25" E o M N 269 s �'•o b IP p��/ ! .610 ACRES 10' access ep5emnt NP S 0 >>°� �` ' o�•a7 s N 7.36 1 `ti 6 O 21 2 W Y 2 07•J6'25 E 3.63' N- T2s .53, _River ti���sc ,• aQ ; :,, off. .,,p, F ,AA �'rtio ��• NIF MOQ �t D.B.120-219 \ mss• , �5 �9 �oX Wo\ke I��, c�k` �It9lt;lo po9e X53 Deed 9� . LEGEND R/W - Right -of -Way EIP - Existing Iron Pipe EIR - Existing Iron Rebar P - Point CM - Concrete Monument NIP - New Iron Placed P/L - Property Line C A - Controlled Access RCP - Reinforced Concrete Pipe CMP - Corrugated Metal Pipe CCP- Corrugated Plastic Pipe -F- 100 year Flood Boundary -0- Overhead Utilities -X- Fence t - Center Line CL - Center Line EP - Edge of Pavement FC - Face of Curb P -Power Pole L�aht Pole H - Mien Hole R - Radius CH - Chord Distance P/0 - Part of SE - Sight Easement D _ Deed Book PPlat Book - jQatch $osjn ence Posstt -S- Sewer Line NOTE : THIS PLAT IS SUBJECT TO AMY EASEMENTS, AeREEfENTS, OR RleNTS OF WAY OF RECORD PRIOR TO THE DATE OF THIS PLAT. RD NORIZCeTAL RECKTIC CONTROL MIONUMNN ARE LOCATED WITHIN fioDO FEET OF TNI$ PROPERTY. TNI• SURVEY 12 SNDJECT TO ANY FACTS THAT WAY SE DISCLOSED fiY A FULL AM ACGMATE TITLE SEARCH. NOT FURNISHED TO 99 AS OF THIS DATE. FRONT OF THE LOTS ARE TO BE FACING THE 60' ROADWAY EASEMENT 200 0 200 GRAPHIC SCALE - FEET 400 600 SCALE I" = 200' SURVEYED: CRC MAPPED: CRC I PLAT FOR I W 40t /4eSrffrE a ,� Q 1� r� s� g o VALLEY '1 River Bend Hills SEE DEED BOOK 120, PAGE 219 PORTION OF PARCEL 49, DAVIE COUNTY TAX MAP B-7 TOWNSHIP COUNTY STATE Farmington Davie North Carolina C. Ray Cates 119 Depot Street Mocksville, NC, 27028 Phone (704) 634-3735 DATE 0'/-17-1996 JOB NO. 3332E MAP NO. 3332F PL1 SHEET ONE OF TWO PtAc:ED WCN f� 4`, a �._E VICINITY MAP L 0 T 3 k' PL. BK. 6, PG. 3 N CAR®''• �Q; OFE..s8I0N�`ti9 SEAL •.< L-2527 SUVO �i�q •........•• TO I. GP.ADY L T,ITTEPC,W. CERTIFr THAT INL,EP Mr' DIRE-TIOr1 AND SUF'ERVISIGN. THIS MAP WAS L'RAWN FROM AN ACTUAL FIELD —LIRVE, MAD& By TUTTERO iURVEYIN,, )MPAN'f FROFESSIOtJ IOU c_0 0 ; OSI _CALF_ IN FEET •, ��' w I TUTTEROW SURVEYING COMPANY IC'' Ni,I? H SAPSBIjR I `_T. 4�• I M11ChSVJLLE, N.C. v�'8 -5 PLAT OF SURVEY FOR, LARRY G. F'RA ZIER __tREVISIONS SCALE, 1 = loo APPROVED BY, DRAWN BY, �ILE NAME, R—BENDIA DATE- APRIL -29-2003 G L TUTTEROW JOSHUA A NAME,RBHILLS1 -69 BEING 1.222 AC TAKEN FROM U^T # 1 AND 1.92' AC TAKEN FROM LOT #: r F THE RIVER BEND 'HILLS SUBDIVISION (PL.BK 6, PG 163) LYING IN FARMINGTON TOWNSHIP DAVIE COUNT't. NORTH CAROLINA DRAWING NUMBER; TAX MAP REF.: B-7, BLOCK. A I 78;-13-3A C' , LINE BEARING DISTANCE L1 N 21'36'44" E 129.18 Ll N 02'09'5.` ­ 'N 6646 L3 N 01'20*nli w 1.)'7.24 •, ��' w I TUTTEROW SURVEYING COMPANY IC'' Ni,I? H SAPSBIjR I `_T. 4�• I M11ChSVJLLE, N.C. v�'8 -5 PLAT OF SURVEY FOR, LARRY G. F'RA ZIER __tREVISIONS SCALE, 1 = loo APPROVED BY, DRAWN BY, �ILE NAME, R—BENDIA DATE- APRIL -29-2003 G L TUTTEROW JOSHUA A NAME,RBHILLS1 -69 BEING 1.222 AC TAKEN FROM U^T # 1 AND 1.92' AC TAKEN FROM LOT #: r F THE RIVER BEND 'HILLS SUBDIVISION (PL.BK 6, PG 163) LYING IN FARMINGTON TOWNSHIP DAVIE COUNT't. NORTH CAROLINA DRAWING NUMBER; TAX MAP REF.: B-7, BLOCK. A I 78;-13-3A RIM BEBID Huls Sheet 1 of � - --PkW and recorded in Plat Bode 6 page --- 162 on July 19, 19% at 3:20 P.M. \ M1A std"ear Od www o� anger vernods, war _ c w /r veer s+� dO GMM* wt 1R°�. i0WAft t Rd `A* "Mill • * .Own 6*ANWN w ft" Is Seek ALM11111L �--.3 so She tM I petera e0 edoftw ► 1 -*Aft ad M ti, - tAN fall So gome� tAA &Z OILER • awanSsd. Illinois ow oiwr •%MI* 4400I00 were ad .. aw 171Mdw 40 JULY ,r 1996 - Seel or Slwq jr slowpor, 2623 _ • 1 RagIMMIIn IIrwO� N,. 0 wpb �y�. l t e Nol•i PIM of to CWN* w1 aft •Rsew" safiy ad C. Rm DNR % w poesh"d Well ispIw. plosIAw oSwaN behm was as ei dw weft wiawls;sfi M some=orf go fb }wf • t«s/� LlL'1� >tlll a sw� R�� OF NeefifF MI eew.ilfie■ sleswe LQ -o gxc r*. .. iZ�,..e Parcel 2 T iMap A-7 G• Walker THIRD Book 77 POge 77 1 THIS PLAT WAS PREPARED TO SHOW A DMSION OF DAVID M. HANES PROPERTY, ALL TRACT SHOWN ARE 5.00 ACRES OR MORE AND DOES NOT CONSMM A4ki8QMS10N AS DEFINED BY THE DAME COUNTY "DN510N REGULATIONS. JESSE BOYCE,JR DIRECTO( OF SAN —D-- Rn The fN°Nlog sortlflset• ("M five MASE !✓046r % -Lb%tL s!f A3d: - 0—mAy AM aFFTIMTi IC1AL E W t OFFICER Slealm 1s s•rtlfles to be correct. Thio dy of le� Probate too geld. L• Hover) fiber's. Register' of D•oods by SAF -AW ISTANT •.4"Ap 1�6. 141 0� r0 d ��o y file.I Tfor regletretlow or 3 ^� s•elo" `' V`le—ii a" reser MA to Plot eeelt Few JIIE.AIL. Mowry here. Register N Deets F II" Fee Pwld ]�//-.•',-•� -- by iC. k 4..L.f�/ fi�.eeISTAM FLOW -� Total _Y � - e Parcel 2.01 �' a 4U �j S 04°28.05"W 97•Fto to. 3 I r94.;a Stephen A-7 I Tax Ma 2'02 t° o I N 9� �, 01• 572.58• X --x— r �r '--------- __ to NIP -x__ P W. Walker P A-7 "!'� 0 `�c�d�°� t 1�� D. B. 160. 618 r` t 7t 33• 482.01- Deed M. Walker N'e° a,` °.`\'vi„�', s, u�. I oa.--' '+ °' Book 179, P °•� "� N 'cero?_N '.1 _ j w N 06'05'30-W t s2. 72.92'. N 671 59 . EIP JEIP °9e 272 Iii i I „o,��•o'ti /� , `0o O '° N C 9 ,� •E ''tor s�a�-- _ .1..-- 0 '48'59'55"W !�?I.r i O W N N 35'44.45"W 74.E its• -�'�1 _ v1 l� ' �a5 h�T f W S 03°0910"W 293.89• ° �'� " ;P �� 4y� CFS 1 162.81' j r� * �s+E i t� ------ ---- 5i�' os� .i t>s -� ��� _ « v�ni h N ---s _ S 03 09' 10"W 549.75' e �� ,y�9 I-- _`vV S 48.47'25"W 123.89' '` N ► 'L C -tp Q "_�c� N -i 56 ,moi —_� fat°". �4� N + m Te !� ?J _. 00 24.4025'1Y 1t2.C1 , E,6 �'h� % � ��N t M / e1 X10 co tp (,+ J� is to9fA �T4T• �t�a• 6 NIP 1 `�. �I z S' Q -k N 14•t3'20"W 74.77 N �! 5 r - .S%9 Q3 U n _ Ifs? _ .%. T �j t!' l ' NIP 00 NIP 2X.89'--- - �g9 loc�C �� ` `�1�~ .$� 60' I� ° C ML PCINf 76.26' u! a 5��6 2Sly ------ ..� s ° o 6 A j �, , s. t' . N _ N Ct•50'1o"w.--_ ti/e o _ '10 POINf 42°20'40"E �-' LA OD '7.816 N J e��9�TlY �ti}� ,y V h O�Oe¢S�7f,.MF PCII�T 'S 50°59'45"E w 0.072 ACR O� f? O . 9� 35' d.iveway easement ��W O� �r0 S. f i 7$.87• N ACRES Z •'� a' g vj 4j� o00 124.22' 42°18'40"E - NIP ry ACRES NIP ,J f o ^i / �B9 124.22' V ^ tr^ 7 9 R �vp ? 4S� iia SToto G s N eh 7 S 6703 ,1 S"W 82.93 . 28.9r " J v A / 11 Qc�t� '' S y 4 )\2�°547 g0 C' c�s`�O\� NIP w'� AC,RES �, ES ,v1P 6.108 ACRE .;o�,' a.�z��',5,, 3 ss4s.w\ /�(.'0�j�'7 �,�o, 3 F \�ti \ R I S r io � p• 24 C, a 0 1 U `d3 0ose`r0 Og.55 NAv EIP OV 4 °f �°,Pol NIP / �� /w �'y ! 1G� i N N 08 33'25" E o M N 269 s �'•o b IP p��/ ! .610 ACRES 10' access ep5emnt NP S 0 >>°� �` ' o�•a7 s N 7.36 1 `ti 6 O 21 2 W Y 2 07•J6'25 E 3.63' N- T2s .53, _River ti���sc ,• aQ ; :,, off. .,,p, F ,AA �'rtio ��• NIF MOQ �t D.B.120-219 \ mss• , �5 �9 �oX Wo\ke I��, c�k` �It9lt;lo po9e X53 Deed 9� . LEGEND R/W - Right -of -Way EIP - Existing Iron Pipe EIR - Existing Iron Rebar P - Point CM - Concrete Monument NIP - New Iron Placed P/L - Property Line C A - Controlled Access RCP - Reinforced Concrete Pipe CMP - Corrugated Metal Pipe CCP- Corrugated Plastic Pipe -F- 100 year Flood Boundary -0- Overhead Utilities -X- Fence t - Center Line CL - Center Line EP - Edge of Pavement FC - Face of Curb P -Power Pole L�aht Pole H - Mien Hole R - Radius CH - Chord Distance P/0 - Part of SE - Sight Easement D _ Deed Book PPlat Book - jQatch $osjn ence Posstt -S- Sewer Line NOTE : THIS PLAT IS SUBJECT TO AMY EASEMENTS, AeREEfENTS, OR RleNTS OF WAY OF RECORD PRIOR TO THE DATE OF THIS PLAT. RD NORIZCeTAL RECKTIC CONTROL MIONUMNN ARE LOCATED WITHIN fioDO FEET OF TNI$ PROPERTY. TNI• SURVEY 12 SNDJECT TO ANY FACTS THAT WAY SE DISCLOSED fiY A FULL AM ACGMATE TITLE SEARCH. NOT FURNISHED TO 99 AS OF THIS DATE. FRONT OF THE LOTS ARE TO BE FACING THE 60' ROADWAY EASEMENT 200 0 200 GRAPHIC SCALE - FEET 400 600 SCALE I" = 200' SURVEYED: CRC MAPPED: CRC I PLAT FOR I W 40t /4eSrffrE a ,� Q 1� r� s� g o VALLEY '1 River Bend Hills SEE DEED BOOK 120, PAGE 219 PORTION OF PARCEL 49, DAVIE COUNTY TAX MAP B-7 TOWNSHIP COUNTY STATE Farmington Davie North Carolina C. Ray Cates 119 Depot Street Mocksville, NC, 27028 Phone (704) 634-3735 DATE 0'/-17-1996 JOB NO. 3332E MAP NO. 3332F PL1 SHEET ONE OF TWO