214 Shady Grove Lane Lot 11^4ry+,•y.s�-..wi..._." c.''i`za' ,,,.. .. ;�r �., F-Nie„.i.,kt....-.�'J.° "S"ur.�BY!°or yv'" .os+s�nc;,aiby�flY >'a `a'-`-.�;'i^ ”-,,; .>-w, V
OrdZATION NO: 0757 DAVIE COUNTY HEALTH DEPARTMENT �j0, oa Qgly ,
Environmental Health Section PROPERTY INFORMATION
Penmttee,I , �}'s `` P O, Box 848
Name " \`� P�'�kC,y\ e�� Mocksville, NC27028 Subdivision Name. �3 "
'iP P rtY Phone#:704-634-8760
Directrohs to ro e , ("4 � ' � . ection:. Lot
AUTHORIZATIONFOR
7: 1 \ uRta WASTEWATER SYSTEM CONSTRUCTION Tax Office PIN: r1Q 1 0 71VD 1 b)
.. , .. t :`•
Road Name: e-ip: 01)
**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/Auttiorization Number should be presented to the Davie County Building Inspections
Office when applying for Buildingpemiits.
(In compliancewith Article 11 of G.S. Chapter f(iOA, Wastewater Systems, Section .1900.Sewage Treatment and Disposal Systems)
( ^� ***NOTICE***.TILS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
• / IS VALID FOR A PERIOD OF FIVE YEARS
ENVIRONMENTAL HEALTH SPECIALIST-.',! DATE ISSUED
..:.
�t: �J ,Y2�/r.i%a 'tq t?'Ji'af.i tiws::aJt >•ti AlD
asmik j DAVIECOUNTY HEALTHDE! PARTMENT
r iIMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
tfw
I3aiu°er \ 141 2 �>L . Subdivision Name:. �T
Tz-
P P Section:' 1 Lot:
r'Diiectronsto ro of
I )ry
. '�.,;\�� .,' ,. `. '`4'+�,, y, k,.�•�:e .PERMIT r Tax OfficeplN:# _-.46 -01V— ...
Road Name:
**NOTE** This Improvement Permit DOES NOT authorise the construction or, installation of a sepfic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the .
constmctiordinstallafion of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section. 1909 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
Y`S,.i'-�- 1 PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST- DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
"TNSTALLING THE SYSTEM.
RESIDENTIAL SPECIECATION:-BUILDING TYPE Osc # BEDROOMS _� # BATHS -I • i # OCCUPANTS L4 GARBA' h DISPOSAL &r No -
_COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE p PEOPLEISHIFI' # SEATS " INDUSTRIAL WASTE: Yes or No
. LOT SIZE iC,uUi TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE ✓ • i REPAIR SITE -
SYSTEM SPECIFICATIONS: TANK SIZE LO -GAL. PUMP TANK GAL. TRENcHwiDTR-3L ROCK DEPTH U LINEAR FT.M1
REQUIRED SITE MODInCATIONS/CONDITIONS:
**CONTACT'A REPRESENTATIVS'OF THE DAVIE;COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.Ma OR 1:00 -' 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
AUTHORIZATION NO.. U -7S7OPERATION PERMTr BY. ' �� - DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE l t 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.
DCrm 05/96 (Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERM FIE
Davie County Health Department(;
Environmental Health Section
R O. Box 848 1 7 1997
Mocksville, NC 27028
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSEII,LTLVI�FCGt'"ALL THE REQUIRED INFORMATION IS PROVIDED. /I// ,,// •/
1. Name to be Billed Contact Person ALL /�E'S�e Y
Mailing, ?ice Y �) N/ '� Home Phone
City/Stateaip 14J1/6'I r?/9,0— -41/f, V 700,/z Business Phone
2. Name on PermitIATC if Different than Above 55A ii i -P
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �� %� r e� 1 WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
Tax Office PIN: # S_71 0q 11mL
1
Property Address: Road Name ✓ 6ro/rL /YL 1 t
1 e
city/Zip 706
If in Subdivision provide information, as follows: ; 1 �d
Name:
1
1
Section: Lot #: r 1
1
This is to certify that the information provided is correct to me nest or my xnowieuge. r unucraMIu uiM M,y FVLHI..k.1
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
as necessary to determine the site suitabiliv.
DATE 2:2
Revised DCHD (06-96)
conduct all testing procedures
Mailing Address
6AW -2— City/State/Zip
1
3.
Application For:
(3 Site Evaluation ❑ Improvement Permit & ATC
❑ Both
4.
System to Serve:
l"House . ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5.
If Residence:
# People # Bedrooms �� #
Bathrooms —a -LL
irDishwasher
O Garbage Disposal O—Washing Machine ❑ Basement/Plumbing ❑
Basement/No Plumbing
6.
If Business/Other:
Specify type # People
# Sinks
# Commodes
# Showers # Urinals #
Water Coolers
If Foodservice:
# Seats Estimated Water Usage (gallons per day)
7.
Type of water supply: 9" County/City ❑ Well
❑ Community
WINO
8.
Do you anticipate
additions or expansions of the facility this system is intended to serve?
❑ Yes
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: �� %� r e� 1 WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
Tax Office PIN: # S_71 0q 11mL
1
Property Address: Road Name ✓ 6ro/rL /YL 1 t
1 e
city/Zip 706
If in Subdivision provide information, as follows: ; 1 �d
Name:
1
1
Section: Lot #: r 1
1
This is to certify that the information provided is correct to me nest or my xnowieuge. r unucraMIu uiM M,y FVLHI..k.1
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
as necessary to determine the site suitabiliv.
DATE 2:2
Revised DCHD (06-96)
conduct all testing procedures
FINAL SUBDIVISION PLAT CERTIFICATE OF APPROvAL
i hereby wrtHy that the subdivision plot shown hereon has been
found to comply with the Carroty Subdivision Regulations, with the
exception of such variances. N any, as are noted In the minutes
of the Planning Board and that It has been approved for recording
In the office of Register of Deeds. It is hereby noted that such
approval for recordation does not include approval to instal and
utilize sanitary fociltles nor does it Include approval for the
construction or occupancy of buildings or structures.'
Th" day
of A 4'a�r,fj%�
Director, Davie Coun
t
1Te foregoing certificate of iI I* QM G .(3t ey
(HERE GIVE NAAE
AND CtFICIAL MU OF THE OFFICER .9WWC
Ru► ,0h CoIto41_N) J'
I] (,
TME CERTIFICATE PASSED L441+�
is certified to be carred This i day of 9abobas, 19%.
Probate fee paid.
by .Henry Shore, Register of Deeds
` 4 s �-
CERTIFICATE OF APPROVAL BY THE PLANNING BOARDS
The Davis County Planning Board hereby approves the find plat for 'SHADY GROVE' Subdiviaton.
This the �doy of October 1496. / / kz4
airman, County Planning Board
i
NIP ca
22-�Q
191.00"
0
0
v
0
r7
W
0
0
a�
C,
00
�r
J
Q
0
t-
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CONC.
CONTROL
CORNER
134.00' 1 130.00' 1 138.00'
L 1 Goo ao
C, � a'
o
Find for Registration at : Z% 1 o'clock P -M
/Yo vent � -
this S- day of.AaRei.r. and recorded In
Piot Book _ Page, �-3
Henry Shorn Register of Deeds
Filing Fee Paid by
m aat .2 1by "'zU .
Deputy — Arsistant
-i— TOTAL 1602.72' S 8.19' 49 W
- l " L--
�J
93.25'_ _ _ _ 12_4.91` _-_-_-_�7.?8'
T I1 T 1 � n .� . r •� r
149.72' \ 128.50
'L John C. Ore), Jr. certify that this map
was drown under my supervision from (* actual
survey mode under my supervision: that the
error of closure as calculated by latitudes
and departures 4 1:20.000; that this map
was prepared In accordance with G.S. 47-30
as amended. Witness my hand and and
t��c
Zy of October. 1996 AD.
3S1
egistered L Su Lioense No.
PARCEL 24, TAX MAP H -f
MARSHALL LEWIS SWARINGI
DB, 120 PG. 439
ZONED R ,'A
141.50
- > 0
a
o _ c+
N
rn
16:
4
rj4 --� --- --
------ F -WAY
20 PAVED PUBLIC ROAD
2.16''• 0W � a -TOTAL -305.94-_-S 9' 53' 49" W - � C: D -�
160 ,Inp P ---------- -- -
C•' 40.00' 150.94'
'715
.00' ` l 6
-� J
W
I e 4/
er
/�04
N� 1 1
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RIGHT -O -
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jOj'4144
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation ,..
SECTION_ LOT
APPLICANT'S NAME DATE EVALUATED �' I
PROPOSED FACILITY �a 0 ,Q PROPERTY SIZE c�
SUBDIVISION _, ROAD NAME
Water Supply: On -Site Well Community Public
Evaluation Auger Boring Pits ✓ Cut
FACTORS
1 2 3 4 5 .6 7
Landscape position
S
Sloe %
c v
HORIZON I DEPTH
"
Texture group,
Consistence
Structure
Mineralogy>
HORIZON R 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
J
CLASSIFICATION
,
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: �5
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-90)
EVALUATION BY:
OTHER(S) PRESENT: "--0,
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
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 OR - 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)
LIAR - Long-term acceptance rate - gal/day/ft2
t DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME / rC/91�C11'[/�i�%� DATE EVALUATED_
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY
LlKtl,11 � (4i(Q;�'lY i
Water Supply: On -Site Well Community Public (�
Evaluation By: Auger Boring Pit r/ Cut -
FACTORS 1 2 3 4
Landscape position L
Slope Z
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH 7 -
Texture groupG
Consistence
Structure /l_ • f /�
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:
LANG -TERM ACCEPTANCE RATE:_
REMARKS:
DCHD (01-901
EVALUATED BY:
OTHER(S) PRESENT:
LEGEND
r
it
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 <;lay loam- SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
Moist
VFR- Very friable FR -Friable FI -Finn 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
.3C -Single grain M -Massive CR -Crumb CR -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/f(2
oD APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health.Department
No. of Sinks
nn Environmental Health Section
of Commodes
P. O. Box 665
No. of Urinals
Mocksville, NC 27028
,a
No of Showers
Water Usage Figures -
Application/Permit Requested By v baron \1r 6" i be
—n rifl[�
r �.J
'G Mailing Address •b1 : 'T�O)C .ao (03
Home Phone cigs- a 34cl
R " clVca rICC , Qc a10
Business Phone —ISR — 2Co 1 c—
%9.", Do you anticipate additions/ex answno the facility this is intended
2 i' Name on Permit if Different than Above —P -)/A-
P-/A-lioation
sytem to serve? ❑ Yes
11 ti for. GYGeneral Evaluation ❑Septic Tank Installation Permit
4 `System to Serve: House ❑ Mobile Home
❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other
❑ .Unknown -
/
house, mobile home: Subdivision �LL 1�rriyL
Section Lot #
❑ Basement/Plumbing
of People
❑ Basement/No Plumbing
` No. of Bedrooms
❑Washing Machine
°No. of Bathrooms
❑Dishwasher
Dwelling Dimensions
❑Garbage Disposal
6. If business, Industry, place of public assembly, other: Specify type
No. of People Served
No. of Sinks
of Commodes
No. of Urinals
of Lavatories
No. of Water Coolers
No of Showers
Water Usage Figures -
7 ,Type of water supply::.
Public
❑ Private
8 `Property Dimensions �(C1Cj{ee
�j ct� _
Sewage Disposal Contractor
%9.", Do you anticipate additions/ex answno the facility this is intended
sytem to serve? ❑ Yes
. If yes what type?
❑ No
NOTE: Improvements Permits shall be valid, from date Issued. Improvements Permits are subject to
revocation, if site plans or the intended use change.. Effective October 1, 1989. 1
PROPERTY INFORMATION REQUIRED:
Tax Office PIN: # S�Jgq — �� Olor-i'i
PROPERTY ADDRESS, as follows:
Road Name:Rl'I'd
C1ty: AA[ nr
SUBMIT A PLAT WITH .THIS APPLICATION.
Revisions effective October 1, 1995. ttt
I,
This is to certify that the information provided Is correct to the best of my knowledge, and I understand I am responsible
Incurred from this application.
DA
for all charges
CONSENT FOR'SITE EVALUATION TQ BE DONE ON ABOVE DESCRIBED PROPERTY
r::IMOST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
=: If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
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 procg�lures as necessary to determine said site's suitability for a ground absorption sewage treatment
' Wand disposal system.
DATE
SIGNATURE I
DAVIE COUNTY HEALTH DEPARTMENT
�( Environmental Health Section
Soil/Site Evaluation
NAME
a
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED 'O-iq/—Q.j�
PROPERTY SIZE Jr e
LOCATION OF SITE r&x. l
Water Supply: On -Site Well Community Public L/
Evaluation By: Auger Boring d/ Pit Cut _ I.
FACTORS
1 2 3 4
Landscape position
Zl
Slo e z
HOR ZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
�—
Texture groupL
Consistence
i
Structure
S /G
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
i�
SITE CLASSIFICATION: 1--f
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
EVALUATED BY: _A�/Z
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 -:lay 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
3C -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
plat of Shady Grove
subdivision off hwy. 801 in Advance..
Lot 11
is classified
provisionally suitable for the installation of a
septic 'tank
system,
If'you
have any
questions feel free to call me.
Sincerely,.
Robert B. Nall, Jr., R.S.
Eff Section