119 Alexandria Court Lot 134
A.
Davie Countv. NC
Tax Parcel R ennrt
Tuesdav, November 29. 2016
WAKNM(i: '1'li1S 1S INU'1' A SURVEY
Parcel Information
Parcel Number:
H8060A0013
Township: Shady Grove
NCPIN Number:
5789245683
Municipality:
Account Number:
8300969
Census Tract: 37059-804
Listed Owner 1:
OSBORNE MARCUS S
Voting Precinct: EAST SHADY GROVE
Mailing Address 1:
119 ALEXANDRIA COURT
Planning Jurisdiction: Davie County
City:
ADVANCE
Zoning Class: DAVIE COUNTY R -A
State:
NC
Zoning Overlay:
Zip Code:
27006
Voluntary Ag. District: No
Legal Description:
LOT 13 COVINGTON CREEK PHASE TWO
Fire Response District: ADVANCE
Assessed Acreage:
1.40
Elementary School Zone: SHADY GROVE
Deed Date:
5/2012
Middle School Zone: WILLIAM ELLIS
Deed Book / Page:
008900678
Soil Types: PaD,WeB,PcC2
Plat Book:
0007
Flood Zone:
Plat Page:
139
Watershed Overlay: DAVIE COUNTY
Building Value:
Outbuilding & Extra
Freatures Value:
Land Value:
Total Market Value:
Total Assessed Value:
9 tu�u�AAll data is provided as Is without warranty or guarantee of any Idmi either expressed or Implied Including but not limited to the
Davie County, implied v a ran as of merchantability or fitness for a particular use. An users of Davie County's GIs website &hall hold harmless the
County of Davie, North Carolina, its agents, consultants, contractors or employees from any and ag daims or cruses of action due to
�7
�� U N l� C or arising out of the use or Inability to use the GIS data provided by this website
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
fikliAldo
APPLICATION IP/ATC OSWW REPAIR �V/ w: jT//
Name OS1�afIVe, Telephone Number 407-
Address 11q
Mailing Address (if different from above)
Email Address: 0SbO/DV9- d 11' ®a 100—mm
Subdivision Name 1Q� e Lot #
Directions�(/ uC �D/ �i
ON
Date System Installed &00 Name System nstalled Under
Type Facility i ase- Number Bedrooms J Number People Served _
Type Water Supply /1 a Specific Problem Occurring
Date Requested Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason
Revised 2-2011
Permitte 's ,, '' DAVIE COUNTY HEALTH DEPARTMENT
Name: ) 04 1 %dpi. Lf L Lk -e I ( t Environmental Health Section PROPERTY INFORMATION
Directions to property: Lt0 L 46 go 5
t+� V& a Co u A -t c3ri b z& 1 c
k 16 A & i h* off C
AUTHORIZATION NO: 002879 A
P.O. Box 848
Mocksville, NC 27028
Phone #: 336 -751 -8760 -
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
Subdivision Name: r,-A.2}lti4+dA l!lceIC
Section: 2L !j Lot:///��� 13
Tax Office PIN:#
RoadName: Ct(cix Zip�zG6i6
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
/ ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
z1A 3o � q IS VALID FOR A PERIOD OF FIVE YEARS.
IRONMENTAL HEAL H ECIALIST DATE ISSUED
Y /.. Q ..' `•... { '. .fir
P M s '` • ' "` DAV.IrE COUNTY HVALTH DEPARTMENT
ertntttee s -y- - ,
It
Name: O t �a<" f o f ` �` 4 Environmental Health Section PROPERTY INFORMATION
LLI� " P.O. Box 848
Directions to property: ^t �" 801
A.Mocksville, NC 27028 Subdivision Name: k j0A l(%te C
Phone #: 336-751-8760
wui �t'� t rt Cd C r �C Ste. Section: Lot: 13
A( AUTHORIZATION FOR Q (�^
16 C'I C`'7 Gwl �•. WASTEWATER M- � q - ��u7
/11��(GNC� tv Tax Off* PIN:#
SYSTEM CONSTRUCTION "(
AUTHORIZATION NO: 002879 A Road Name: A1 I?yei t, de(I zin,) 7Ct6
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
_O TICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
O' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS# OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE r� TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 1 V NEW SITE REPAIR SITE v
1
SYSTEM SPECIFICATIONS: TANK SIZE / GAL. PUMP TANK/ GAL. TRENCH WIDTH 36 r f ROCK DEPTH &A- LINEAR FT v
OTHER A � I ` ILC t� � T P U i S
d\
5 d R
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
I I1
Y6400 'P 9
`4
to sM
�p5
i
_ate �
eg.-�-iceKu^— �-,
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
AUTHORIZATION NO.
OPERATION PERMIT BY:
SYSTEM INSTALLED BY:
DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TIDE SYSTEM DESCRIBED ABOVE 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.
DCHD 02/02 (Revised)
Perm ttj's l� r
DAV
f, ,IE COUNTY HEALTH DEPARTMENT
Name: C9 i 'a� 1t j Environmental Health Section PROPERTY INFORMATION
?
P:O. Box 848 f
Directions to property: Lf } k" ` 1 Mocksville, NC 27028 Subdivision Name: (�f 't�l`A�� Uh i i�'' c r- /C
// Phone #: 336-751-8760
1wA C �U Cri Cd r, I{ �N Section: ' Lot: 13
AUTHORIZATION FOR
OR
WASTEWATER!'
SYSTEM CONSTRUCTION Tax Office PIN:#
AUTHORIZATION NO: 002879 A Road Name: PYCt c, C. v Zip
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
r C� — *** TICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
(J
oe IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED 41RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS � �7
# BATHS, J # OCCUPANTS 4_ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
Q,
LOT SIZE rActTYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) V NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE / GAL. PUMP TANK��GAL. TRENCH WIDTH 3G ROCK DEPTH Alk LINEAR
F172t
OTHER i'! /!' �-�' 1 ` �Gt Y� P U P5
p(rCA re-x;R-� )9C.
� f�
REQUIRED SITE MODIFICATIONS/CONDITIONSC4 st11 -e-d ,:'
IMPROVEMENT PERMIT LAYOUT
71
Ji � wt
I
if"
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
I
OPERATION PERMIT
SYSTEM INSTALLED BY:
N
AUTHORIZATION NO. OPERATION PERMIT BY: r''' DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TAE SYSTEM DESCRIBED ABOVE 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 F6kXNY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised)
**NOTE** This Authorization for Wastewater System"Construction MUST:BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
. r- t -j' G� G "(�l✓ IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 1_/ # BATHS # OCCUPANTS k/ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE t C TYPE WATER SUPPLY C DESIGN WASTEWATER FLOW (GPD) i [J NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE1,0047 ,4jq,0
GAL. PUMP TANK GA/L. TRENCH WIDTH 36 ROCK DEPTH111A LINEAR FT.
()TI -TPR i'4 /•7-41— "1" . `l. � '�. / C" �LY
f � � 1 P 6 P5
/ A
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
�a
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT:TI'3E SYSTEM DESCRIBED ABOVE 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 hdI '`ANY GIVEN PERIOD OF TIME. r tr
DCHD 02/02 (Revised) i ' '
I TM...,f.4 .
Pemuttee,s,�;, "�y. DAVIE COUNTY HEALTH DEPARTMENT
�'
Nath:=` _) G 4 4 u =' f..� 4 j ' `" I
Environmental Health Section
PROPERTY INFORMATION
1- f
P.O. Box 848
Lt
i
Directions to property:
Mocksville, NC 27028
Subdivision Name: )(,A!5!
CN
ai t €' C. (( . ' i < . 9 ✓ .' t
Phone #: 336-751-8760
Section:
Lot:
AUTHORIZATION FOR
WASTEWATERTax
Office PIN:# �- `�
i
p
41
SYSTEM CONS'T'RUCTION
-
! t 6l
-�
(I
AUTHORIZATION NO: 002879 A
Road Name: `✓ ,1., t.
f
A e zip:a`
**NOTE** This Authorization for Wastewater System"Construction MUST:BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
. r- t -j' G� G "(�l✓ IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 1_/ # BATHS # OCCUPANTS k/ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE t C TYPE WATER SUPPLY C DESIGN WASTEWATER FLOW (GPD) i [J NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE1,0047 ,4jq,0
GAL. PUMP TANK GA/L. TRENCH WIDTH 36 ROCK DEPTH111A LINEAR FT.
()TI -TPR i'4 /•7-41— "1" . `l. � '�. / C" �LY
f � � 1 P 6 P5
/ A
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
�a
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT:TI'3E SYSTEM DESCRIBED ABOVE 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 hdI '`ANY GIVEN PERIOD OF TIME. r tr
DCHD 02/02 (Revised) i ' '
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O. Box 848/210 Hospital Street
Courier #09-40-06
Mocksville, NC 27028
Phone#: (336) 751-8760
Fax#: (336) 751-8786
May 1, 2008
Joe & Tina Brunelli
119 Alexander Court
Advance, NC 27006
Dear Mr. ,& Mrs. Brunelli,
On April 8, 2008 you submitted an application for the addition of a pool to
your home. Mr. Joe Mando visited the site and determined that the location
that you proposed for the placement of your pool would not interfere with
the septic system or its repair area.
Upon request by you, this office was asked to determine if the pool could be
placed in the rear of the home. After revisiting the site, the rear of the
home, where the septic system exists, is designated for the current system
and a partial repair. The front of the home must be used for the remainder
of the repair area. The septic system and repair area must not be disturbed
for any addition or expansion.
If there are any comments, concerns, and/or questions, please don't hesitate
to contact me using the above information.
Sincerely,
Robert M. Nations, RS
Environmental Health Specialist
n
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
'Mocksville, NC 27028 d
Phone: (336)751-8760 0
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING RECONNECTION ❑
Name: <� E'_ + . / t I �� Ry U n el I / Phone Number: ^� ' / Qll 3 (Home)
Mailing Address: % / ! �� y �+ i i c� r� �y ��i-i (Work)
ork
V64 )I
Detailed Directions To Site: 'V-1 of(e)0 190 Fn 1 SO u l 1 t 6 �lZ h) le , _8")1A
S! -r
d,� le /j 7i 1 4i Coyln,-,-&i C r e e l�' !�L,i/1irl I)7 -c v..' /C /"/*/�
_ Property Address:
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under :�„� h,0#01V &S/ 1U4,! d A) Type Of Dwelling: bus -6
Date System Installed(Month/Day/Year): 0 0 Number Of Bedrooms:Number Of People:
is The Dwelling Currently Vacant? Yes ❑ No-E�If Yes, For How Long?
Any Known Problems? Yes ❑ No R�"' If,Yes, Explain:
Please Fill In The Following Information About The New. Dwelling:
PO
� c3�Type Of Dwelling: 6 Number-Of43edroums: Number Of People:
jequested By: Date Requested
:
(Signature)
_:. Far -Environmental Health;Office_Use _Only=
Approved M -''Disapproved ❑
Comments: Z,
4��
Av
Environmental Health Specialist /)/1, Date
*The'signing of this form by the Environmental Health Staff is in noway intended, nor should betaken as a
guarantee(extended or limited) that the on-site wastewater system will function properly for any given period of fiime.
Payment: Cash ❑ Check Money Order ❑ # 1/04(33 Amo $ >'�%�• >� Date: �o
Paid By: h _ Received ByJ
Account #: Invoice
�11 m eel- bu c ,
Account #: 989900093
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Billed To: Shelton Construction Services
Reference Name: Con Shelton
Proposed Facility: Residence -
ATC Number: 2223
Tax PIN/EH #: 5789-245683
Subdivision Info: Covington Creek Sec.2 Lot # 13
Location/Address: Alexander Court27006
Property Size: 1 Acre
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED bythe 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: Date: //^�� a
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on pr ement/Operation Permit
has been installed in compliance with Article 11 of G.S. Chapter 130A, Section .1900 Se age Treatment and
Disposal Systems," but shall in NOWAY betaken as a guarantee that the system wil fun ion satisfactorily for any
given period of time.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
jib
Date: 5 S1 f� - O�
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900093
Billed To: Shelton Construction Services
Reference Name: Con Shelton
Proposed Facility: Residence
ATC Number: 2223
Tax PIN/EH #: 5789-245683
Subdivision Info: Covington Creek Sec.2 Lot # 13
Location/Address: Alexander Court -27006
Property Size: 1 Acre
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: 64a�Date: // ",-9a
if
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on I
has been installed in compliance with Article I 1 of G.S. Chapter 130A, Section .1900
Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will
given period of time. /
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
ient/Operation Permit
Treatment and
satisfactorily for any
jib
Date:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Ja.e �T - V,« Br�Kel
Account #: 989900093 Tax PIN/EH #: 5789-245683
Billed To: ices Subdivision Info: Covington Creek Sec.2 Lot # 13
Reference Name: Con Shelton
Proposed Facility: Residence
Location/Address: Alexander Court -27006
Property Size: 1 Acre
ATC Number: 2223 t: ( rt A ( -e %f cL"kr / C
**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.
i
Residential Specification: Building Type #People #Bedrooms f #Baths S
Dishwasher: Garbage Disposal: ❑ Washing Machine: er" Basement w/Plumbing: ❑ Basement/No Plumbing:
d.
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow (GPD) Site: New Repair ❑
System Specifications: Tank Size A10 GAL. Pump Tank GAL. Trench Width Rock Depth Linear Ft.
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone # is (336)751-8760.****
Environmental Health Specialist's Signature:_ Date: Z.,eh
AV
DCHD 05/99 (Revised)
' A0PUCA710N Fon SITE EVALUATION/IMPROvEMEM PERmfI' & ATC I D
Davie County Health Department
4. Eni tvnmenta/ Health Sectfon
VeA POr P.O. Box 848/210 Hospital Street
Mockaville, NC 27028
(336)751-8760
***1NPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. LRefer to the INFORMATION BULLETIN for instructions.
/ /
1. Name to be Billed S h I T -- c- o We 4-. c.4 Contact Person _ [p'
MailSaq Address) �s -7 LJ S /-�✓ � � � Som. Phon. (9 �' ' Z c� Z�
city/state/alp /77a _,e i) C Business Phone _ 3 `f — Z z"'.." l"
2. Name on permit/ATC if Different than
Mailing Address
3. Application, For: %-te Evaluation
Permit/ATC 0 Both
s. System to service: Uffonse . 0 ,Mo//bile Home - Business 0 Industry O Other
s. If Residence: # People 7 # Bedrooms # Bathrooms
015ishwasher 9,69Aage Disposal .Thing Machine O Basewst/Plumbiaq 0,81a'ament/no Plnmbinq
6. Sf ausLness/industry/others specify type
# People # Sinks
# commodes # showers # Urinals # water Coolers
IF FOODSERVICE: d Seats Estimated Water Usage /gallons Per day)
7. Type of water supply: �ty/City 0 Well 0 Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes 42BB-'
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either* PLAT or SITE PLAN MUST BE SUBAUTTEd by the client with THIS APPLICATION.
Property Dimensions: I A r- -- t
Tax Office PIN: # -5-'7 S J -Z y S to 71 -
Property
Property Address: Road Name R l C - ` - G f
City/ZIp X7000
If in a Subdivision provide Information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from Mockwille) to PRC.-ER'l'Y:
—yo L-" A 4-, 8ra1 S
Date Property Flagged: / OJ '—q Z'1 `7
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 ase change, or if the information
submitted In this application is &billed or changed I, also, understand that 1 am responsible for all charges Incurred from
this applkadon. I, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located In Davie County and owned by
to conduct all testing procedures as necessary to determine the site suitability.
DATE Z _�/ 7 SIGNATUR`
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).
f�
Jr.
Revised DCHD (07/99)
Site Revisit Charge
iDate(s):
Client Notification Date: _
I EHS:
Account No. 6799
Involce No.
r.
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT
Davie County Health Department
Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
(704) 634-8760 1
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE RE UlI-R�E1/D INFORMATION IS PROVIDED.
1. Name to be Billed r.,%e Contact Person /
Mailing Address [l >1 Home Phone
City/State/Zip ,// UCS/d Ce Business Phone ?q9-'y%7.:L If �8/3439/e
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: V4ite Evaluation [ ] Improvement Permit & ATC [ ] Both
4. System to Serve: [) House Mobile Home [ ] Business (] Industry [ ] Other �•Z % t�'�' Su,E]Of'1 I!/S/nom
5. If Residence: # People # Bedrooms # Bathrooms [ ] Dishwasher [ ] Garbage Disposal
[ ] 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: County/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes Hilo
If yes, what type?
1111111? ,( PLAI 01? 5111 PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***A' FLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: AXzr+ &C. OrtC-e WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: # S" 789 _ a'I - _� ; �J,t� ci �Sa 1�� �. nLp tg 1 el )u e e
Property Address: Road Dame So 1 D r n /( / m ► — t�LS -� 5 Io�Q a� gi
Cit 2?0o b c
City/Zip 1�� 'del) M m e r5 l
/Zi V •
If in Subdivision provide information, as follows:
Name: ,Cbl /A-n+dAJ Oreek. Y�rcr�oszd
i
Section: 1 Lot #• @—
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
ve of the Davie County Health Department to enter upon above described property located in Davie County and owned
Revised DCHD (06-96)
SIGN
all testing proceaWs as necessary to determine the site suitability.
1'1118 AREA ,%fA l LiE 11SEb r01? b1?,18VINCG J0111Z SITE PLAN:
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section SECTION_z LOT
` Soil/Site Evaluation
APPLICANT'S NAME i�b �' DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISICN C�L�All &et ROAD NAME Zra Z
Water Supply:
On -Site Well Community,
Evaluation By: Auger Boring Pit i
Public G�
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
i� S
Mineralogy
. I
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
77
LONG-TERM ACCEPTANCE RATE
, V
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RA'
REMARKS
DCHD (01.90)
EVALUATION BY: ,&
OTHER(S) PRESENT:
/ LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope
Texture
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
oist
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