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130 Brook Rose Ln DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street ` Mocksville,NC 27028 (� (336)753-6780/Fax# (336)753-1680 Q"'y 1 REPAIR OPERATION PERMIT 11 Account #: 990005997 Tax P1N!EH#: J70000007702' Billed To: Nancy Wright Subdivision Info: Reference Name: EXPANSION : Location/Address: 130 Brooke Rose Lane-27028 Proposed Facility: Septic Up-Grade , Property$izor ,;.'1.339 Ac ATO'oNe1 *T68Muance of this Operation Permit shall•indicate the system described on the ATC has been installed in compliance with Article 1 I of G.S.Chapter 130A, Section .1900 "Sewage Treatment and Disposal Systems," but shall in NO WAY be taken as a guarantee that the system will function satisfactorily for any given period of time. -1h��rckvr �B e�c�s+,�q t�c�s�in5 ex;s}� System Type: o roq f S.T.Manufacture J Tank Date zSCrryte Tank Size d `5 Pump Tank Size Bedrooms System Installed By:Wbowim"i `Installer#: Date: GPS Coordinate: 3l V Amca view J, I+tr io r m ' Coyux�4e •r errs++, r a Environmental Health Specialist: AA Dater.2H-16 t I DCHD 11/06(Revised) V Weis DAVIE COUNTY ENVIRONMENTAL HEALTH P.O.Box 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780/Fax#(336)753-1680 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account #: 990005997 ®� P: Tak.:PIN1EH#: J70000007702 Billed To: Nancy Wright Subdivisio i.in w. Reference Name: EXPANSION Q.LtzcaflohrAdc3es 130 Brooke Rose Lane-270287; Proposed Facility: Septic Up-Grade i�PtbIre ty!$ive?r..r-1.339 Ac 1 Site Type: ONew ❑Repair KExpansion AT Number: 6015 **NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental Health Section prior to.issuance of any building permit(s),(in compliance with Article 11 of G.S.Chapter 130A Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat or the intended use change. Residential Specifications: #Bedrooms #Bathrooms #People i BasementO Basement plumbingO Non-Residential Specifications: Facility Type # People—#Seats Square Footage(or Dimensions of Facility) Lot Size �I'M MCType of Water Supply: OCounty/City OWell ❑Community Well System Specifications: Design Wastewater Flow (GPD) Tank Size)l GAL.Pump Tank GAL. TrenchWidth� Max.-Trench Depth !``3Rock D4 Linear Ft. Site Modifications/Conditions/Other. Contact the Da 'e County Environmental Hedlth Section for final inspection of this system between : 0—9:30a.m.on the day of installation. Telephone# 336 751-8760. Environmental Health Specialist Date: _ AQ DCHD 11/06(Revised) t 1836 I Tax Map: Address: S' Installer: 0 U �1 EHS: Date: Operation Permit Inspection Checklist Location and Separation Distances 1. Distance from septic tank/pump tank to foundation/basement � feet 2. Distance from system to well if applicable feet 3. Any other setback(.1950)requirements Supply line 1. Material supply line is constructed of �' diameter inches 2. Length of supply line(2'min.) )'Z 3. Amount of fall in supply line(1/8"per foot min) L/ 4. Distance from ST/PT to the nitrification field/dist.device) feet Septic Tank/Pump Tank 1. Visually inspect top of tanks(s),interior&exterior walls,baffle wall and bottom 2. Any honeycombing or exposed rebar present? Circle: YES or 3. Visually inspect sanitary tee,lids,and air vent for proper installation and sealant 67ood 4. Tank Serial Numbers:STB PT 5. ST w/in 6"finished grade?Circle: YES or NO 6. Date of manufacture:ST PT 7. Liquid capacity of tanks ST PT 8. Effluent filter type 9. Pipe penetration seal present?Circle: YES or NO 10. Riser(s)present?Circle: YES or No Riser Type 11. Pump Tank riser 6"above finished grade?Circle: YES or NO 12. Riser approved?Circle: YES or NO Nitrification Field 1. Septic Tank outlet elevation 2. Trench Depth Readings(inches)_-42 3. Number of Trenches. 2 Distance between trenches 4. Trench Width 31i'l fr Aggregate material type and size 3 4 5 6 57 (Circle) .ft! Aggregate Depth(inches) 7. Nitrification lines installed on contour?Circle: (� or NO ,V Innovative system type Installer certified for installation?Circle: YES or NO 9,.�2'earthen dam between ST(or d-box)and beginning of nitrification line?Circle:YES or NO yd. Stepdowns a. 2'undisturbed earthen dam(s) Circle: YES or NO b. Proper rise over stepdowns?Circle: YES or NO c. Solid pipe used? Solid,Corrugated or other? d. Elevation of each stepdown e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO Distribution Devices 1. . Type Is the device watertight? Is it level? 2. Distance from Dist.device to trenches feet 3. Record elevations:Inlets Outlets -. ;, .. � a _ - - p �. i � _ ' , �-; � ` Davie County Health Department � 1836 Environmental Health Section • ` , P.O. Box 848 w1 0 210 Hospital Strect 0 U�� Courier# : 09-40-06 Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: Phone Number 3 J�b' 7 �� je (Home) Mailing Address: a v �`r-od ILL 0.1�—[�`( 3 3� — q 3 / - Z 3 /Z (Work) V c t/4S 1/1 At, A)C k-20 2_1 Email Detailed Directions To Site: !1 '7 CCQ�S �iC /- �L ��DCJ 1. ,55;9 U Property Address: Please Fill In The Following Information About The EXISTING Facility: •i 7000-00-0'?7 Oz Name System Installed Under: `J d Type Of Facility: 140U-j_.e_ Date System Installed(Month/Date/Year): Id—2-3 —47/ Number Of Bedrooms: 3 Number Of People: Is The Facility Currently Vacant? Yes No If Yes,Four How Long? y V Any Known Problems? Yes No If Yes,Explain: / d Please Fill In The Following Information Ab-out The NEW Facility: Type Of Facility: 041U& &I _-}(.Z- Ndmber Of Bedrooms: Number of People Requested By: Date Requested: (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *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 given period of time. Payment: Cash Check Money Order # Amount:$ /d 0, Date: Paid By: Received By: 41 Account#: 0947 Invoice#: ��/ w"Fy ,t LX> r �, G �� ,<<, •, �' DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION *NOTE:*Issued in Compliance With Article II of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Name —J�2&i1 i°rtJ xm—'f_,jig, -I �!,/fi..r/� Date ."g.? N27 Locati n 5 4 Q Subdivision Name Lot No. Sec. or Block No. Lot Size �����' House Mobile Home _ Business Speculation No. Bedrooms Z No. Baths__ _ No. in Family_ Garbage Disposal YES ❑ NO p' Specifications for System: Auto Dish Washer YES [j7 NO ❑ Auto Wash Ma:hine YES m NO ❑ Type Water Supply *This,permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. i:2 Ir Improvements permit by *Contact a representative of the Davie County.Health'Department for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Numbar 704=634-5985. Final Installation Diagram: System Installed by Certificate Completion �� Date Cert of p ning of this certificate shall indicate that the system described above has been installed in compliance with idards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function `only for any given period of time. C� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ( Davie County Health Departmen Environmental Health Section i VHASBEEN 4*'� P. O. Box 665Mocksville, N.C. 27028CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PER Home Phone (,A 44__6- �o 1. Permit Requested By Business Phone 2. Address &F ELA S • A,&,' 3. Property Owner if Different than Above R,NM i,,: L , 9 �A ka� A. A,& A/ _ Address Ifo Y ALL `�V R,,y Pn 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House-,,L Mobile Home Business IndustryOther b) Number of people .,�o�6L 6. ay If house or mobile home, state size of home and number of rooms. House Dimensions 40 / 'y i! aD X w/ g�� °2C"R G �atV Ci yas7'cRy� Bed Rooms Bath Rooms .2,&Den w/Closet AZd:f b) If Business, Industry or Other, State: Number of persons served 21 G S -- /J7QDLi�— What type business, etc. Estimate amount of waste daily (24 hours) A Number and type of water-using fixtures: A commodes -3 urinals garbage disposal lavatory co showers washing machine dishwasher 1 sinks 8. a) Type water supply: Public %Z Private Community o b) Has the water supply system been approved? YesDb��No 9. a) Property Dimensions X /ASO e �A!1 AA6 y, b) Land area designated to building site -moi -e Ne 5?e2 �n��P1�2(• c) Sewage Disposal Contractor egdg fes. 7`'i/1ff' 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Va What type? This is to certify that the information is correct to the best of my knowledge. . 0 8`9 v Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: L47;vak j6iAii�)b 14,6AidA>1',e RB6 ks "TWAI &i>o'�Ah5 —Vil 71' 0-.06- 7_41/4p -� is r3 .)46-661 X ads �LOWi !t� °N �a�t'Q. O ;y *NOTES Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. i Effective October 1 , 1989. DCHD 18.82) \ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name �' 1'��, Date /mfrs Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S� PS S SSS U U T 2) Soil Texture (12-36 in.) Sandy, S Loamy, Clayey, (note 2:1 Clay) (9 "•� U U U 3) Soil Structure (12-36 in.) � � S„ Clayey Soils L (fU 4) Soil Depth (inches) & -(A—PW7 (PP P U U �U,S 5) Soil Drainage: Internal � CS -� S_ External U U U 6) Restrictive Horizons 7) Available Space S 4s) PS PSS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U� U 9) Site Classification 10,5, 1 1 ,, U—UNSUITABLE �L S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described byTitle Date SITE DIAGRAM Ir �g UCHO(6•82) rasa Far aeasraaT+oa November 20,1991 12:15 PM DaTZ m.z W TAXABLE CDNSIDct:.t i i b i'ATED aao aecainao N aooall(il_r.•.0=.j •VNIrr L a"oft fte"Talt OF CLLDa . OayR VOLffrT.NC ss s an Excise Tax Recording Time,Boot and Page TaxLot No.............................................................................................. Parcel Identifier No.......:....................,.............................................. Verifiedby.........................:.............................................. County on the................day of........................................................1 19............ by ......................................... .................................................................................:.................................................................................................... Mail after recording to ......Grantee,,••108..Elm,.Street, Hocicsville, N.0 2.7.0.218 .. ... ........................................................................................................................................ This instrument was prepared by....RRb..e1C.C..H,.„ .fsbe plc,,,:Jr..,,.Attorney,:,et•.,1,aw,,..MQ,q}cQyi,�1g,,,,NC,,,2702$,..,.,..,,, Sri ef description for the.Index 13.307 acres NORTH CAROLINA )GENERAL WARRANTY DEED THIS DEED made this:....:.�.�...,day of.......t1/Ql�: +.!t6<..............................19...:9.1...,by and between GRANTOR GRANTEE JOHN R: ALLEN and wife, COUNTRY ROAD LOG HOMES OF DAVIE COUNTY, INC. KAY F. ALLEN Enter In appropriate block for each party:name,address,and,it appropriate,character of entity,aq.corporation or partnership. The designation Grantor and Grantee as used herein shall include said parties,their heirs,successors,and assigns,and shall Include siniru ar,plural,masculine,feminine or neuter as required by context. WITNESSETH, the the Grantor, for a valuable consideration paid by the Grantee, the receipt of which is hereby acknowledged,has and by these presents does grant,bargain,sell and convey unto the Grantee in fee simple, all that certain lot or parcel of land situated in the City of................. ............F.lilton..................... Township, Davie..............................,.. County,North Carolina and more particularly described as follows: BEGINNING at a stone in the line of Wiley S. Potts (DB 63, page 101), Northwest corner of George R. Everhardt (DB 28, page 67) and running thence with Everhardt line, South'08 degrees 46 minutes 57 seconds West passing througha nail at 1,485.28 feet for a total distance of 1,532.96 feet to an unmarked point in the center of U.S. Highway 64 right of way; thence with the center of said right of way. North 78 degrees 58 minutes 31 seconds West, 378.0 feet to an unmarked point in the center of said right of way; thence with the line of John D. Osborne (DB 98, page 440) North 08 degrees 30 minutes 08'seconds East passing.through an iron pin in a stump at 48.95 feet for a total distance of 1,506.72 feet to a dead Oak stump, Wiley S. Potts Southwest corner in the line of John D. Osborne; thence with Potts linle, South 82 degrees 55 minutes 23 seconds East, 385.24 feet to the POINT AND PLACE OF BEGINNING containing 13.307 acres, more or less as surveyed October 27, 1987 py Tutterow Surveying Company and being a portion of those lands described by deed recorded in Deed Book 65, page 478, Davie County Registry. For reference see Deed Book 151, page 545. DEED TRANC,'ca N.C.gar Aa .Fame No.J C 1976.R-6,d©1977—,.wwu,w.•w,,..,..aa.qa r,xa„ur.h.e.„a•a �7..,''�� ��; �.:.M 4..-i wwn n.,,.C.ar Esc I BK451 PG490,.. Exhibit"A"Childress • Lying and being in Fulton Township Davie County North Carolina and beginning at a new iron;said new iron being located in the Western line of Torie L.Boan DB 332 page 952;said new iron located North 08 degrees 46 minutes 57 seconds West 982.93 feet from a stone;said stone being the Northwestern comer of said Boan and being located in Southern line of Lucille M.Potts DB 63 page 101 WB 94 E 64;thence from said new iron and with Boan line South 08 degrees 46 minutes 57 seconds West 226.26 to a new • iron;thence North 81 degrees 42 minutes 07 seconds West 170.88 feet to a new iron; thence South 10 degrees 58 minutes 09 seconds West 249.41 feet to a new iron;thence South 10 degrees 58 minutes 09 seconds West 30.00 feet to point;said point being located in the center of US Highway 64;thence with center said of highway North 78 degrees 58 minutes 31.seconds West 25.00 feet to a point;thence North 10 degrees 58' minutes 09 seconds East 30.00 feet to a new iron;thence North 10 degrees 58 minutes 09 seconds East 524.72 feet to a new iron;thence South 77 degrees 23 minutes 50 seconds East 185.77 feet to the POINT AND PLACE OF BEGINNING and containing 1.339 acres as surveyed by Tutterow Surveying Company November 21,2002 and being 1.339 acres of the David L.Childress property DB 322 page 722 lying in Fulton Township Davie County North Carolina Tap Max Reference 1-7 part of 77 Also reserved herein is a 25 foot access easement of Ingress,egress and regress to remaining property owned by grantor said easement beginning at a point in the center of US Highway 64;said point being the Southwestern comer of the herein above described . property;thence North 10 degrees 58 minutes 09 seconds East 554.72 feet to a new iron; said easement being 25 feet in width;said 25 feet extending to the East along herein described line parallel with the full 554.72 feet contained herein. • ,r �e t {�� }fi �'} �j t ; ,.�y�yy'i.�.� f µhY�� rP'iJ�h' y�sj 3�1 r• {.. t'+j tr �„yc_ y•V 4hv'rY f � i.L y +f 9 vtt'.4� aU*'}yF�$f_ 'R'c pYr +' Yt� ti t��' - .rte •t' f'8' "a 1. .t .y.�•'�r tJ`w i 9 •t'.R'�Sd �.e. ..,, j t 1 1.r�.YYlo�{1:.+,�, J. 4� ..����Yr-:l�lrt(' . Appraisal Card Page 1 of 1 DAVIE COUNTY NC 1/2/2013 9:10:52 AM RIGHT NANCY L Retum/Appeal Notes: 37-000-00-077-02 907 E US HWY 64 UNIQ ID 19622 2525699 4003-1-12 ID NO:5767896226 C COUNTY TAX(100),FIRE TAX(100) CARD NO.1 of 1 Reval Year:2009 Tax Year:2013 1.339 AC HWY 64 1.220 AC SRC=Inspection Appraised by 02 on 04/09/2008 04003 NO CREEK TW-04 C- EX-AT- LAST ACTION 20100922 CONSTRUCTION DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE S oundation-3 Eff. BASE Standard TO.1800C �? ontinuous Footing5.0 US MO Area UA RATE RCN EYB AYB CREDENCE TO MARKET ub Floor System-4 I ood 8.0 01 01 1 707 121 83.49 14251 19911991 %GOOD 82.0 DEPR.BUILDING VALUE-CARD 116,87C TYPE:Single Family Residential Single Family Residential DEPR.OB/XF VALUE-CARD x[erior Walls-16 y MARKET LAND VALUE-CARD 18,74 --r. nthetic Stone 33.00 STORIES:2-1.5 Stories TOTAL MARKET VALUE-CARD 135,61 r- oofing Structure-03 able 8.0 oofing Cover-03 _ OTAL APPRAISED VALUE-CARD 135,61 %sphalt or Composition Shin le 3.00 OTAL APPRAISED VALUE-PARCEL 135,61 nterior Wail Construction-5 )rywall/Sheetrock 20.0 nterior Floor Cover-08 OTAL PRESENT USE VALUE-PARCEL heet Vinyl/Laminate 6.00 OTAL VALUE DEFERRED-PARCEL nterior Floor Cover-14 OTAL TAXABLE VALUE-PARCEL 135,61 :arpet 0.0 PRIOR eating Fuel-04 UILDING VALUE 96,04 lectric 1.00 BXF VALUE eating Type-10 LAND VALUE 12,04 eat Pump 4.00 RESENT USE VALUE r Conditioning Type-03 DEFERRED VALUE entral s 4.0 OTAL VALUE 108 08 3edrooms/Bathrooms/Half-Bathrooms +-16--+ 3/2/0 12.000 1 F U 5 I 1 1 drooms 4 4 L AS-IFUS-2LL-0 throoms +-----3 0-----+ PERMIT AS-1 FUS-1 LL-0 I F G D I CODE DATE NOTE I NUMBER AMOUNT OTAL POINT VALUE 104.00 1 1v I I r BUILDING ADJUSTMENTS 2 2 OUT:WTRSHD: v uallty 3 AVG 1.000 2 2 SALES DATA ha a Desi 4 FACTOR 4 1.050 I I k INDICATE a lie 3 Size 1.100 DATE DEED SALES o +5+-----30-----+ +-----32-----+ OTAL ADJUSTMENT FACTOR 1.16 4 4 B A S I I F B M I M R TYPE / / PRICE OTAL QUALITY INDEX 121 +W D D I I I 1 00 WD Q 1 13500I I I I 11 00 WD I 9000 ^' I 2 2 2 1 4 4 4 7 I 1 I I I I I +-----32-----+ +-----32-----+ HEATED AREA 1,760 B F 0 P 8 +-----32-----+ NOTES SUBAREAUNIT ORIG% SIZE ANN DEP % OB/XF DEPR GS OD UA DESCRIPTIO LTH H NIT PRICE GOND BLDG#L/ FAR Y EY RATE V :OND VALUE TYPE AREA %RPL CS OTAL OB XF VALUE AS 768 1001 6412 BM 76 288881 GD 66 2479 - - OP 256)3 751 S 224)9 1686 DD 2 2 33 REPLACE 1-None SUBAREA 2,69 142,51 TOTALS UILDING DIMENSIONS BAS-WIFGD=N22W30S22E30$W31S3 WDD=WSS4ESN4$S21FOP=S8E32N8W32$E32 N24$PTR=N25FUS-W16N14E16S14$S25E25FBM=E32S24W32N24 W25$. ND INFORMATION IGNEST THER ADJUSTMENTS LAND TOTAL IG BEST USE LOCAL FRON DEPTH/ LND COND NO NOTES ROA UNIT LAND LINT TOTAL ADJUSTED LANG LAND SE CODE ZONING TAGE DEPT SIZE MOD FACT RF AC LC TO OT TYPE PRICE UNITS TYP ADJST UNIT PRICE VALUE NOTES URAL AC 0120 25 0 2.2300 4 0.9700 03+10+00-10+00 PW 7 100.0 1.22 AC 2.16 15 357.3 1873 OTAL MARKET LAND DATA 1.22 18,74 OTAL PRESENT USE DATA http://maps.co.davie.ne us/ITSNet/AppraisalCard.aspx?parcel=J70000007702 1/2/2013