134 Windemere Drive Lot 12I.% • HEALTH DEPARTMENT RELEASE
dFA7Fv Davie County Health Department
�r 210 Hospital Street
.� P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Michael Boone
Address: 134 Windemere Drive
City: Advance
State0p: NC 27006
Phone #:
For Office Use Only
*CDP File Number 190787-1
County ID Number:
`valuated For: HDR/WWC
PERMIT VALID 0 3/ 3 1/ a 0 a 0
I I AITI I
("Ip—roperty Owner: Michael Boone
Address: 134 Windemere Drive
City: Advance
State2ip: NC 27006
�,Phone #:
Property Location & Site information
Address 134 windemere Drive Subdivision: Windemere
Road# Advance NC 27006
SINGLE FAMILY Township:
'Structure: Directions
# of Bedrooms: # of People: Hwy 158, right on Baltimore Rd. and left on Beauchamp.
Phase: Lot: 12
'Water Supply: N/A
Basement: F-1 Yes a No
'Proposed Improvement:
Pool
Type of Business:
Total sq. Footage: No. Of Employees:
The septic system will need to be moved and protected by a french drain as displayed in the attached drawing
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? OYes ONO,
ApplicantlLegal Reps. Signature: *Date:
*Issued By: 2140 -Nations, Robert
Authorized State Agent
*Date of Issue: 0 3/ 3 1/ a 0 1 5
**Site Plan/Drawing attached.**
O Hand Drawing OlmportDrawing
HEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Type: Health Department Release
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CDP File Number: 190787,-,1,,
County File Number:
Date: 03 l 3 1 l a 0 1 5
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Scale: . OBlock � .ft.
Q N/A
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Davie County Health Department
O iia T Environmental Health Section
+ e P.O. Box 848
210 Hospital Street
0 � Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780
ON-SITE WAS CERTIFICATION
(Check One) Replacement Remodeling Reconnection,
Fax: (336) - 753-1680
Name: �l �' G �-f �,�L D 00 Ai5' n Phone Number (Home)
Mailing Address: W6<_ 6r J/ tZ • (Work)
r
7 006'Email Address: ,, J
Detailed Directions To Site: .9I M Ll G��MM 7y �Q ih% Y F, M 6� V9 C' . f , �yt V l'S l (9
Property Address !;141q r
Please Fill In The Following Information About The EXISTING Facility: r
Name System Installed Under:
Date System Installed (Month/Date/Year):
Type Of Facility:
Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes 6 If Yes, For How Long?
Any Known Problems? Yes If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: Number Of Bedrooms: Number of People
Pool Size: G a e ize:
Requested By: + j/ 4jt���d: /
gnature) POP' L' -7V,? " 7 [ f0
For Environmental th Office Use Only
Approved DisapprovedCAM
rr��
Comments: 470U
Environmental Health Specialis Date:
*The signing of this form by tl Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) th the on-site wastewater system will function properly for any given period of time.
Payment: Cash heck Mo y Order # Amount:$ C9 • Q C Date:__,.�
Paid By: �7 c( Received By:
Account #: Q' I U Invoice #:
120 120 '388. f 2 'ILA
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Printed:Jan 30, 2015
All data, is pMvid0d as is VAthGutwarrantY 07quararztee ollNary kind either expressm-d or implied including but not limited to the implied warranties
of merchantability or fitness for a particular use.
All users of Davie CounWs GIS websito 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 wabsite.
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All data, is pMvid0d as is VAthGutwarrantY 07quararztee ollNary kind either expressm-d or implied including but not limited to the implied warranties
of merchantability or fitness for a particular use.
All users of Davie CounWs GIS websito 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 wabsite.
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900063 Tax PIN/EH #: 5870-69-4192.12
Billed To: Larry McDaniel Subdivision Info: Windemere Farms lot # 12
Reference Name: Janice McDaniel LocationlAddress: Windemere Drive -27006
Proposed Facility: Residence Property Size: 0.943 Acre
ATC Number: 2324
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 CON IS V . ID FOR A PERIOD OF FIVE YEARS.
s ---
Environmental Health Specialist's Signature: Date:
��zr n� i ;s �'0 2. 3 roomS
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.
a
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05199 (Revised)
P2,,: 7 N T-
Date:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #:
989900063
Tax PIN/EH #:
5870-69-4192.12
Billed To:
Larry McDaniel
Subdivision Info:
Windemere Farms Lot # 12
Reference Name:
Janice McDaniel
Location/Address:
Windemere Drive -27006
Proposed Facility:
Residence
Property Size:
0.943 Acre
ATC Number: 2324
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 CON T IS VLID FOR A PERIOD OF FIVE YEARS.
.0 --
Environmental Health Specialist's Signature: V Date: u0
P-rzrn i4 � s�'� 2, 3 &df-aoms
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.
�o
5
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
lOo�
T
Date:
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' DAVIE COUNTY HEALTH DEPARTMENT yU
• Environmental Health Section2,2`�
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #:
989900063
Tax PIN/EH #:
5870-69-4192.12
Billed To:
Lary McDaniel
Subdivision Info:
Windemere Farms Lot # 12
Reference Name:
Janice McDaniel
Location/Address:
Windemere Drive -27006
Proposed Facility:
Residence
Property Size:
0.943 Acre
C NCuO�& 2324
**N E** 'Phis mprovement/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
ylwsz
#People #Bedrooms 3 #Baths -2-
Dishwasher: 20" Garbage Disposal: ❑ Washing Machine: M,-- Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size 0,145 AU6Type Water Suppl)eOOA)W Design Wastewater Flow (GPD) -3 Site: New D---R--epair ❑
System Specifications: Tank Size _jLX)C)GAL. Pump Tank GAL. Trench Widtlk.-Z.,2__ Rock Depth j2— Linear Ft.S0 t
Other: 2 D4STP-1 �JTIo ., 3py.LsS , 1�S'�AL-L 1,1:•S-1'O.C• M� 1.�.
1
Required Site Modifications/Conditions: 4 --SS �A� t�� C-a^rc�.�2 C� H�St=, �►=' % JOS
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER. RISERS) 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.****
Zs•
0 s o �',�`
�M»J,
Environmental Health Specialist's_
DCHD 05/99 (Revised)
.''
Fol S �ST�
V& CU
p,e4otL-To arm cams-'
Ic"-� ofN`—
Date: 211 J lOD
APKICATION FOR SRE EVA1.11AnON/IMPROVEMEN17 PERM A ATC
Davie County Health Department R@ lEQ W IE
'. fib r, v,,y rerlea,NW10sbcwon p
P.O. Box 849/210 Hospital Street
Ttoakaviile, NC 2702e FEB 7 (U]
(336) 751-8760
***Ib1pOR=NV** THIS APPLICATION CAMVT BE PF4=8ED MMZSS ALL T=I R3Qt nm
IHa'OPM210H IS PROVIDED. Refer to the IN!'OI=TiOH BMZTIN for ia*tru'otlons.
1. spe to be sidled l.O� �r r �i (Ylct�Gt 11 c e I T l I c rS contact person ids. (n4v-,vtl iC
Nailing Address
-P. O , > >c J 9 ,41
soM peons 4�t
- au a�a
City /stati/sip
Cr t � —
r �U( "
r t cam/
a' l ooZ a snsiness "me
C) a
a
2. Uaas on perait/A=
it Different than Above
Nailing Address
mr//state/sip
2. Application Tor:
0 Site Evaluation
81Improvsmnt P.rait/ATC
Both
s.. system to Service:
`�j House 0 Mobile Hom O Business 0 Inftstsy
0 Other
S. If Residence:
/#`People
# Bedrooms _ # Bat ==s,
Dishwasher a Garbage Disposal washing Machine a O sasetasnt/ao pinsAing
6. Zf su@iness/2nduatry/others specify type # people # sinks
# coaaodas # shower@ # Urinals # water Coolers
IF TDODSERVICs: g Seats Estimated Rater Osage (galls per day)
7. Type Of water supply: County/City 0 well 0 COMM ty
s. Do you anticipate additions or expansions of the facility this system Is Intended to serve? 0 Yes %No
If yes, what type?
***IMPORTANT"** CLIENTS MIDST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN /IBE SLMW]T ED by the sheat with THIS APPLICATION.
Property Dimensions: S 31 rl • �-� •' WRTTE DIRECTIONS (tiros Mockni1k) to PROPERTY:
Tax Office PIN: # 'S q b io 19 J \C�-
Property Address: Road Name r -C , l �N o o A-V
City/Zip Moa _g _ Dq WL..Q
If in a Subdivision provide information, as follows:
Name: arsrns
Section: Block: Lot: *I
Date Property Flagged: a
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, U the site plans or intended use change, or if the information
submitted in tbb application Is fats fled or changed I, also, understand that I am responsible for all charges inesmd from
sills appUcadoa I, hereby, give consent to the Authorized Representative of the Davis Canty Health Department
to enter upon above described property located Is Davis Canty and owned by
to conduct all testing procedures as necessary to determine the site
DATE A000 SIGNATURE 4LL-4f.�
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Incl a all of the f 4W. E:bdng and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Revised DCHD (07/99)
IDate(s):
I Clint NodMication Date:
IFM'
+a
Account No. U ��
Invoice No. �al
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NOTE:
This property is subject to all easements, right—of—ways,
streets and assessments, if any, as the some may appear of PB 7
record in the office of the Register of Deeds, Clerk of Court,
Town or County Tax Office or which may have been acquired by PG 1 0_3
prescriptive use. This survey is subject to any facts that may
be disclosed by a full and accurate title search, NOT furnished
as of this date.
This map or drawing and any accompanying
documents are furnished to the person(s) named Y High Meadows Road /
thereon and no alterations or use by others e -
Z
is permitted unless authorized by m p.
Stone Land Surveying Co. 0 60' Public R/W 20'+1- Pavement
r a v
Map not for recordation. y ', t� \ 11►►
Precision 1:10,000+
I
� m
o 0 T Bar
deT 13ar
\ W/COP / I
"'O'l-00 \
LEGEND
Call Table for Property Line Following
Western R/W of High Meadows Road
COURSE
R/W —Right—of—Way
Center Line
&7—
L-1
EIP — ExistingIron Pipe
Center Line
EP — Edge of Pavement
L-2
EIR — Existing iron Rebar
FC — Face of Curb
3�
CM -Concrete Monument
IRS — Iron Rebar Set 1/2"
PP — PP�oh Pole
H — I,fgn Hole
F
L-4
P/L — Property Line
Radius
C — Chord Distance
L-5
C A —Controlled Access
of
RCP — Reinforced Concrete Pipe
S S ght
CMP — Corrugated Metal Pipe
DB — Deed Book
CPP — Corrugated Plastic Pipe
PB — Plat Book
CB — Catch Basin
—F— 100 year Flood Boundary
Overhead Utilities
�S- —_Fence Post
—O—
—X— Fence
96 —�ack o� Curb
60 0
60 120
180
GRAPHIC SCALE — FEET
declare h
we surveye3 ti��) proptY.wr>; c
this pla:
T�1
�E
qa
N
T Bar
W/cap
w
c
10 a,
O)
T Bar
w/cap
High Meadows Rd
p
E �
o ..
g y
o m
Windemere Or
Mocks Ch Rd
SR 1623
Vicinity Map (Not to Scale)
SCALE
1"=60'
SURVEYED.
MT,TD
MAPPED:
GRS,AS
Survey for:
Larry K. McDaniel
Lot 12
"WINDEMERE FARMS"
Plat Book 7 0 Page IOJ
0.946 Acres +/— by coordinate computation
TOWNSHIP COUNTY STATE
Shady Grove Davie North Carolina
GREY ENGINEERING, INC.
Civil Engineering and Surveying
P.O. Box 9 Mocksville. N.C. 27028
greyengineering.com (336) 751-2110
DATE
2-4-2000
JOB NO.
S1900
MAP NO.
S1900
Call Table for Property Line Following
Western R/W of High Meadows Road
COURSE
BEARING
DISTANCE
L-1
S 2305725"E
47.99'
L-2
S 0604828"E
71.42' Chord Rad: 200'
L-3
S 03025'47"W
57.57' Chord Rad. 200'
L-4
S 10014'19"E
123.50' Chord Rad: 260'
L-5
S 24000'20"E
108.67'
SCALE
1"=60'
SURVEYED.
MT,TD
MAPPED:
GRS,AS
Survey for:
Larry K. McDaniel
Lot 12
"WINDEMERE FARMS"
Plat Book 7 0 Page IOJ
0.946 Acres +/— by coordinate computation
TOWNSHIP COUNTY STATE
Shady Grove Davie North Carolina
GREY ENGINEERING, INC.
Civil Engineering and Surveying
P.O. Box 9 Mocksville. N.C. 27028
greyengineering.com (336) 751-2110
DATE
2-4-2000
JOB NO.
S1900
MAP NO.
S1900
I
r APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT T
Davie County Health Department
• Environmental Health Section
P. 0. Box 848 FMI
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSEVUNL••ESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
4.
1. Name to be Billed J c s�//i k1 D'0'y Contact Person 6 P444,4 404
Mailing Address ��% %� %1'�► 1 10ire i'� tt� Y Home Phone
City/State/Zip w 7� 4cv 5A- Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: C'l'--Site Evaluation ❑ Improvement Permit & ATC ❑ Both
4. System to Serve: O House ❑ Mobile Home ' O Business O Indust i`., ❑ Other
S. If Residence: # People # Bedrooms =L.W # Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other:
# Commodes
If Foodservice:
7. Type of water supply:
Specify type # People # Sinks
# Showers # Urinals # Water Coolers
# Seats Estimated Water Usage (gallons per day)
al-C-0-unt'y/City ❑ Well
❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
TION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
P"O_ S
r
Property Dimensions:
1 WRITE DIRECTIONS (from
Tax Office PIN: # S�'�
Mocksville) TO PROPERTY:
/
1 6 y C—/4 S I � �e-<- 1�_
Property Address: Road Name 4a tq-iwd
1
City/Zip UA)t/'P_P
QZH
1
If in Subdivision provide info ation, as follows:
/�
1
alName:
Section: / Lot #:
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
59
S to conduct all testing procedures
as necessary to determine the site suitability.
DATE (� �� SIGNATURE
Revised DCHD (06-96)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION_/ LOT
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED �"W
PROPOSED FACILITY 1✓ PROPERTY SIZE
2 —�
SUBDIVISION �1'✓ • :1?.ua ROAD NAME l u
Water Supply:
Evaluation By:
On -Site Well
Auger Boring
Community
Pit
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
5,6.e
Mineralogy
,` , I
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
1
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
LEGEND
DCHD (Ol •90)
Landscape Position
EVALUATION BY: &/Z
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
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