184 Boxwood Church RdDavie Countv. NC Tax Parcel Renort Wednesdav. October 12. 2016
WAKIVIN(�: '1'1i15 l� iVU'1' A �UKVLY
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Parcel Information
Parcel Number: N600000106 Township: Jerusalem
NCPIN Number: 5755203637 Municipality:
Account Number: 79881000 Census Tract: 37059-807
Listed Owner 1: WILLIAMSON MASUKI M Voting Precinct: JERUSALEM
Mailing Address 1: 184 BOXWOOD CHURCH ROAD Planning Jurisdiction: Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-20
State: NC Zoning Overlay:
Zip Code: 27028-6611 Voluntary Ag. District:
Legal Description: TRACT 2 WILLIAMSON Fire Response District:
Assessed Acreage: 0.73 Elementary School Zone:
Deed Date: 11/1992 Middle School Zone:
Deed Book / Page: 001660152 Soil Types:
Plat Book: 0008 Flood Zone:
Plat Page: 154 Watershed Overlay:
Building Value: 66830.00 Outbuilding & Extra
Freatures Value:
Land Value: 15750.00 Total Market Value:
Total Assessed Value: 83360.00
No
JERUSALEM
COOLEEMEE
SOUTH DAVIE
Pc62,PcC2
DAVIE COUNTY
780.00
83360.00
�,V / AII data is provided as ls without warranty or guarantee of any kind either expressed or Implied Including but not Iimlted to the
9�"' �' Davie County� implied warranties of inerchantability or fitness for a particular use. All users of Davle County's GIS wobsite shall hold harmless the
County of Davie, North Carolina, its agents, eonsultants, contractors or employees from any and all elalms or causes of action due to
�'o�,��yq'� NC or adsing out of the use or Inability to use the GIS data provlded by thls website.
Permittee s.-, , DAVIE COUNTY HEALTH DEPARTMENT
Name:��+=' �` %� a�`��'� "`��� t'3 ��� 1�''' �� �%� `�� ��' Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to pmperty: l'� �' �� �- `%� h1ocksville, NC 27028 Subdivision Name:
�: ., .,1,,' � ,'• � , � ; �, Phone #: 336-751-8760
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Section: Lot:
AUTHORIZATION FOR
`',` ! �•, i' • i �,� ��� WASTEWATER Tax Office PIN:#
' � , SYSTF,M CONSTRUCTION - -
AUTHORIZATION NO: p� `� �''t ' � A Road Name. �-1 - j � ` �-= �!' �i � ` �'�Zip: � r �� �
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**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv Environmental Health Section prior
to issuance of any Building Permits. This Fonn/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)
! t / � ' � � , ***NU71C�*** 7'H15 AUTHOKI7,ATION FOR WASTEWATER CONSTRUCTION
�..--�r"i (; << { 4'- ���.%i 1:� i,�� ��'' C� %,_.� �'-�� IS VALID FOR A PERIOD OF FIVE YF.ARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE� ISS �ED
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RESIDENTIAL SPECIFICATION: BUILDING TYPE �� # BEllROOMS � # BATHS % # OCCUPANTS � GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFI' # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE TYPE WATER SUPPLY �, 1 DESIGN WASTEWATER FLOW (GPD) " r �fEW'STTE REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZE ' X 1`:- �,/a'L. PUMP TANK �`!r� GAL. TRENCH WIDTH ��'r'rl ROCK DEPfH 9`" r LINEAR FT. 7�r �r �
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OTHER ��T� ���15��� . ._`?(i I7 �� j �1���1 ��� t_`
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REQUIREDSITEMODIFICATIONS/CONDITIONS: �'i �it°��/' ���� ���5'�F i�l�, � Q�- " %�'-{r"C( ��� %_��j� }'7''(!l�C�f� 4!'� •
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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:
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AUTHORIZATION NO. �,� OPERATION PERMIT BY: DATE: C� T
'�THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE �
WITH ARTICLE 11 OF G.S. CHAP'TER 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 01102 (Revised)
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Permittee s'��` D�1VIE COUNTY HEALTH DEPARTMENT
N�; •a"" � � �'-;1 `� '� � `� � •-'-� + !�' F r� S Y` Environmental Health Section PROPERTY INFORMATION
_ , ` ; �. P.O. Box 848
Dire�tions to property: ' 1 -- L• �"' Mocksville NC 27028 Subdivision Name:
! Phone #: 336-751-8760
_ � �.r �+ i �, ` ; < � ;. t�� 1 r � � '�' ' Section: Lot:
� AUTHORIZATION FOK
. ., ' ; " �„p '' WASTEWATER Tax Office PIN:# - - -
SYSTEM CONSTRUCTION
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AUTHORIZATION NO: � � `� � "� � A Road Name: ' � � �' � � � ' ` ' �Zip:
I**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 Fonn/Authorization Number sho�id be presented to the Davie County Building Inspections
Office when applying for Building Pennits.
,(ln compliance with Article 1] of G.S. Chapter 130A, Wastewater Systems, Section .] 900 Sewage Treatment and Disposal Systems)
_ ,
� t ***NO ICE*** THIS AUTHORI7.ATION FOR WASTEWATER CONSTRUCTION
�..�r'.t { �-:'L i ° ,� y� �1 1 ,,':`� ' `t� �.�' "� �- �� IS VALID FOR A PER(OD OF FIVE .YF.ARS.
ENV[RONMENTAL HEALTH SPECIALIST ' DATE ISS �ED
RESIDENTIAL SPECIFICATION: BUILDING TYPE �� # BEDROOMS �' # BATHS 7 # OCCUPANTS �- GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
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LOT SIZE TYPE WATER SUPPLY C.,� DESIGN WASTEWATER FLOW (GPD) I3E�'STl`E REPAIR SITE
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SYSTEM SPECIFICATIONS: TANK SIZE X��.� �GAL. PUMP TANK �U � GAL. TRENCH WIDTH �^�� �" ROCK DEPTH I2 LINEAR FT. Z<<I�'
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OTHER �`��Q t'�`i`�;�,r�C� ";h �� �� � /�t'w� `_= f/.F �r I �.,1 (1r�'i.���.
REQUIRED SITE MODIFICATIONS/CONDITIONS: �! f r f" i.- "� C{ ! � 11 C. �( i' a � r. �� ,,, ! l���( ;� �j�" �� C G�� y l"(�lf'C -ti e�'� .
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IMPROVEMENT PERMIT LAYOUT `, �J � i�"�<<'1 •
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FOR FINAL INSPECfION 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:
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C � , '-r% ,�� DATE: / r� C� �
AUTHORIZATION NO. � OPERATION PERMIT BY: 'iu` � .,
+tTHE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE 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 0?102 (Revised) � �. � �
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DAVIE COUNTY HEALTH DEPARTMENT
` ° ' • V ' Environmental Health Section
. Soil / Site Evaluation
APPLICANT INFORMATION
Water Supply: On-Site Well Community
Evaluation By: Auger Boring Pit
FACTORS 1 2 3
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: ' �
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PROPERTY INFORMATION
Public �
Cut
5 6
EVALUATION BY: �n�� �Q��I.��m��.
OTHER(S) PRESENT:
REMARKS:
LEGEND
T,�ndscape Position
R- Ridge S- Shoulder L- Linear slope FS - Foot slope N- Nose slope
CC - Concave slope CV - Convex slope T- Tenace 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 Ioam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C- Clay
.ONSI T .NG .
�415�
VFR - Very friable
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NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very �rm EFI - Extremely firm
SS - Slightly sticky S- Sticky VS - Very Sticky
SP - Slightly plastic P- Plastic VP - Very plastic
Sr� t�r
SC - Single grain M- Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
7
Mineraloev
1:1, 2:1, Mixed
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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
Classifcation - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2 DCHD OS/OS (Revised)
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���OUNTY HEALTH DEPARTMENT
�i vironmental Health SeC��on
PO Box 848/210 Hospital Street
` Mocksville, NC 27028
, Phone: (336)751-8760
L�V�iiC�V ���'' ;: 1' i�',1.},._` .1� • �I.,
ASTEWATER CERTIFICATION FOR DWELLING
eck One) REPLACEMEN� REMODELING ❑ RECONNECTION ❑
Name:��� �/ fh��? � j� ��C:.' � C /� �t! ��✓L Phone Number: � �'Y � %r��� �' S �� ,�� (Home)
Mailing Address: �- 5' �� S� % / �� %�� i� l�, � -' YS = �',� Cj �i (Work)
(.��,�:i;_t..i� � �`'r�- (=} ,�'� � Z. � ��7C`� � —�C.t �{�
Detailed Directions To Site: Li � /� ��� �- x f � L ` �' � � �� �
, �'� 3 �,.�t��%-- ��� c`� �,�� �.. �� i�� � �► �.o►,� ji s� �'
Property Address: ���( `- �--���' C.-{.� t,-�� c'Y �� �: J� z`i �� �
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: �' /3" S �-' � � r �� � �� � �'� � y��%``i� Type Of Dwelling: = �i'�i' :: � r ,
Date System Installed(Month/Day/Year): �// "�%:s Number Of Bedrooms:_�Nwnber Of People:�
Is The Dwelling Currently Vacant? Yes ❑ No � If Yes, For How Long?
Any Known Problems? Yes ❑ No�Y" If Yes,
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: _������/����:�+• � Number Of Bedrooms: -� Number Of People: -Z
Requested By:.
;�'"
For Environmental Health Office Use Only
Approved L9' Disapproved 0
Environmental Health
� .� �
Requested• " Z � �C �
G
'"'The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
guazantee(extended or Iimited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash ❑ Check ❑ Money Order ❑# Amount: $,
Paid By: Received By:
Account #: �Z� Z Invoice #:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Sect�on � �
PO Box S48/210 Hospital Street
Mocksville, NC 27028 '
' Phone: (336)751-8760
. ��.
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMEN� REMODELING o RECONNECTION ❑
Name: "�' ..�;/,��,� ��''� /�r��' � (i� �d �/�- Phone Number: � �' `� � ��1 �"" d � � � Home
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Mailing Address: c'..�� S � � / ,/���� ��' 1�.. j��f � �'��" �',�. U '+j (Work)
���� ��"'!�'- �, . � �r� � ;,- �'4,.� �-'�;�- -. `�C, f;"( ,
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Detailed Directions To Site: r' � � ` � � ct. / �� � �'' � �r � �-� ,
�,� � :i/G,�GM €� � C`_ "e� t,t,_r`'.�. � � �� ` � �� �''�„�/ y,e i� �' ,.� �' .�"`
Property Address: �,���% �" /��'�',�' L�r� �r� � � � Lc. l� � '�� �r�c� .
Please Fill In The Following Information About The Existing Dwelling:
_ �
Name System Installed Under: '�`� O'i�-,� � � � •° � °�-�'�' � > �S� � Type Of Dwelling: .<'+��D e. � �'
��� "`� ��Number Of Bedrooms: Number Of People:�
Date System Installed(Month/Day/Year):� _�
Is The Dwel�ing Currently Vacant? Yes ❑ No � If Yes, For How Long?
Any Known Problems? Yes ❑, Na,Ja�' If Yes, Explain:
Please Fill In The Following Information About The New, Dwelling:
Type Of Dwelling: ��C�l,-' J�srr Number Of Bedrooms: -� Number Of People: �--�
Requested By:_
�,�� �y
"� �"`��%l. ,
' Tw � ��
>ate Requested: � "- � � � 4�`
, For Environmental Health Office Use Only.
Approved �'`�Disapproved ❑
Environmental Health
t!
"�The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a
guarantee(extended,or limited) that the on-site wastewater system will function properly for any Qiven period of time.
Payment: Cash<(7'�wCheck�❑ MoneyOrder❑ # Amo/uynt:f�$ ���rf} Date: `%4'��:'.�,'+�(� d\
i' t` % ,a/ . . �. � i �
Paid By: Received By: •. � 1)`i P�O�', �' �,,���,'
Account #: ✓'��� r� • Invoice #: v_ t��'' `,� ���