197 Browder Ln �avie County, NC Tax Parcel Report /-� �'�� Monday, October 3, 201 t
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WARNING: THIS IS NOT A SURVEY
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; Parcel Information
Parcel Number: G7070A0010 Township: Shady Grove
NCPIN Number:. 5860536167 Municipality:
Account Number: 82526344 Census Tract: 37059-803
Listed Owner 1: COOK MICHAEL E Voting Precinct: WEST SHADY GROVE
Mailing Address 1: 197 BROWDER LANE Planning Jurisdiction: Davie County
City: ADVANCE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27006-0000 Voluntary Ag.District: No
Legal Description: LOT 10 BALTIMORE TRAILS Fire Response District: CORNATZER-DULIN
Assessed Acreage: 9.99 Elementary School Zone: SHADY GROVE
Deed Date: 4/2006 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 006590728 Soil Types: SeB,EnB,RnD,MsC
Plat Book: 0008 Flood Zone:
Plat Page: 277 Watershed Overlay: DAVIE COUNTY
Building Value: 421140.00 Outbuilding&Extra 42740.00
Freatures Value:
Land Value: 72490.00 Total Market Value: 536370.00
Totai Assessed Value: 536370.00
��I All data Is provided as Is without warrenty or guarantee of any kind elther expressed or Impiied Ineluding but not Iimited to the
9��'�F Davie County� Implied warranties ot merchantabllity or titness tor a particular use.All users of Davie County's GIS website shall hold harmless the
�7/-� County of Davie,North Carolina,its agents,consuitants,contrectors or employees from any and all claims or causes oT action due to
�OUN�S 1\l_, or arising out of the use or Inabiiity to use the GIS data provided by this website.
. � • •
Davie County Health Department
��ivf� Environmental Health Section
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�, � .; P.O.Box 848 � : �
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� ��;� 210 Hospital Street Il '
r}.- �, ' Courier# : 09-40-06 �g��
- � � . Mocksville,NC 27028 �
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: �c�L c �c/ Z. Phone Numb er_3 3�" `�� —�c�� (Home)
Mailing Address: hvw � (Work)
�- (JGt,K C.�_ ��•�� Email A� ss:
Detailed Directions To Site:
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Properiy Address: Y1�
--� ease Fill In mh�F�llawirrg-Iirf6rmatio -baurT-he-��'I�T-I�VGFacility:
Name System Installed Under: �7C� Type Of Facility: �C/
Date System Installed(Month/Date/Year): ��� Number Of Bedrooms:� Nuxnber Of People:
Is The Facility Currently Vacant? es No If Yes,For How Long?
Any Known Problems? Yes No If Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility:J�W►w��t�(.c, �vo� Number Of Bedrooms: Number of People
Pool Size: � ;/ � ar ge 'ze: Other:
Requested By: Date Requested: � - Z z --/ �
(Signature)
For Environmental Health Office Use Only
Approved Disapproved �G��
Comments: ,'���}�(/ �7"'� C!7 U 1'j'1 �Il�� �%��''�y' ��� �(!,1����
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Environxnental Health Specialist Date: ,2 /5�
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*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:$ Date:
Paid By: Received By:
Account#: Invoice#:
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, • DAVIE COUNTY ENVIRONMENTAL HEALTH G�b
� • ' P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
OPERATION PERMIT
Account #: 990005275 Tax PIN/EH#: 5860-53-6167-Weil
Billed To: Mike Cook Subdivision Info: Baltimore Trails Lot# 10
Reference Name: Location/Address: Baltimore Trails-27006
Proposed Facility: Residential-Well Property Size: 10 Acres
ATC Number: 4974 V� w
�
**NOTE**The issuance of this Operahon Permit shall indi te the system described on the ATC has been installed
in compliance with Article 11 of G.S.Chapter 130A,Sectio .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. C f � � � C�r "f �Q ( / �1�1�
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System Type: S.T.Manufacturer /� 4 Tank Date Tank Size �l�l
Pump Tank Size�� �
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System Installed By: �Y ' E.H.Speciali t: /��� Date:_!�� --L�
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DCHD 11/06(Revised) .
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� DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760 Fax#(336)751-8786
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990005275 Tax PIN/EH#: 5860-53-6167
Biiled To: Mike Cook Subdivision Info: Baltimore Trails Lot# 10
Reference Name: Location/Address: Baltimore Trails-27006
Proposed Facility: Residentia! Property Size: 10 Acres
ATC Number: 4974
Site Type: ew ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MIJST BE ISSUED by the Davie County Envirorunental
Health Section prior to issuance of any building pemut(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 ! BasementC3Basement plumbingC��
Non-Residential Specifications: Facility Type D G�� #People #Seats
Square Footage(or Dimensions of Facility) �tp;l r t�-S in k
Lot Size �O a GP�CS Type of Water Supply: ❑County/City �Well ❑Community Well �
/ �
System Specifications: Design Wastewater Flow(GPD)�Tank Size l�GAL.Pump Tank�GAL.
r► ,� � � /
Trench Width 3� Max.Trench Depth�� Rock Depth� Linear Ft.��('�
Site Mociifications/Conditions/Other: �.�6 l��2(1 ca-G� �h vt s�S�"�'�
. .
Contact the Davie County Environmental Health Section for final inspection of this system�-between` ate
8:30—9:30a.m.on the da of installation. Tel hone# 336 1-876 ."" � �N `�
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Environmental Health Specialist Date: r p� �Q �
DCHD 11/06(Revised)
' , - � � ' � Davie County Environmental Health
• ' P.O.Box 848/210 Hospital Street
• � Mocksville,NC 27028 ',-'��.
(336)751-8760/Fax(336)751-8786
IMPROVEMENT PERMIT � �
. ��
Account #: 990005275 Tax PIN/EH #: 5860-53-6167-Well
Billed To: Mike Cook Subdivision Info: Baltimore Trails Lot# 10
Address: 495 Deep Ravine Court Location/Address: Baltimore Trails-27006
City: Winston-Salem Property Size: 10 Acres ;;
Reference Name:
Proposed Facility: Residential-Well
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this`office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
revocation if site pl s,plat or the intended use change.
� ,
Permit Type: ew ORepair ❑Expansion Pernut Valid for: 5 Years ❑No Expiration �
�- � 0�
Residential Specifications: #Bedrooms�#Bathrooms J'�#People�Basement8'$asement plumbingEi-�_X.��
��`0
Non-Residential Specifications: Facility Type #People #Seats �j� r
Square Footage(or Dimensions of Facility) �/ �
Design Flow(GPD): Q� Type of Water Supply: ❑County/City ClWell ❑Community Well /
i
Site Modifications/Pernut Conditions: � J
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S stem T e LTAR /
Initial -{��1 .
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Site Plan ���p
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Environmental Health Specialist - Date � �7 ��
i.p.l I-06
, .� . .
' APPLICATION FO� SIT� EVALUATION/I � �� �� � ATC
Davie County Environme �
P.O.Box 848/210 Hospit et �
Mocksville,NC 27 �:�AY 1 1 2009
(336)751-8760/Fax(336) - 86
Application For: ❑ Site Evaluation/Improvement Permit ❑ Authori tion To(�Ii�sf�"�u"�E��� � � �Bot
Type of Application: L'XNew System ❑Repair to Existing System ❑Exp E or Facility .
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed_ �►►tc.WA6C. �� Contact Person_µtcKREL coolc (�►tKE)
Billing Address yQ5 Dt�f► Rau►n(E c;r. Home Phone�3�,.��5-4y��
City/State/ZIP w►Ks�aN sa«m Nc, z�1o3 Business Phone 3310•391-9�Va ��a�,.; ,T�(I
�� � �
Name on Permit/ATC if Different than Above � —�f �
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged .��l-0'1
NOTE: A survey plat or site plan must accompany this application. Included: �Site Plan ❑Plat(to scale)
(Pernut is valid far 60 months with site plan,no expiration with complete plat.)
Owner's Name rntc.paFc ?rnAuatcY c�k Phone Number 33�-7�5-4�'T
Owner's Address_yq5 oEEP�..v„�E cr. City/State/Zip�,,�,�cns sau�m ,r.ic 2��3
Property Address City
Lot Size �p p,� Tax PIN# 5&�o53btb7
SubdivisionName(if applicable) 6�t�ClmoctE -rep�S Section/Lot# �ar �o
Directions To Site: � _ � � g�,,, �N�
PRO?L�i�t �3 A'1' EAtO oF BRo�+�DF4 LN ow� GEPi: �TRAMPo4K6 J71�AtYAR-1M025C- T7CRIl.l7e Oo�L QRoPEfLTi�
If the answer to any of the following questions is"yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? ❑Yes �No
Does the site contain jurisdictional wetlands? ❑Yes �No
Are there any easements or right-of-ways on the site? �I'es ❑No pS SKowN � S� p�N,
Is the site subject to approval by another public agency? ❑Yes 9No
Will wastewater other than domestic sewage be generated? ❑Yes�No
IF RESIDENCE FILL OUT THE BOX BELOVV
#People Y #Bedrooms 5 #Bathrooms c,�,5 Garden Tub/Whirlpool C�'es ❑No
Basement: �Yes ❑No Basement Plumbing: �Yes ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacilityBusiness BA�t Total Square Footage of Building �ga, #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type systemrequested: �Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City Water �4 New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑No
If yes,what type? � �L
This is to c�rtify th�t the information provided on this application is�ue and correct to the best of my knowledge. I iuiderstand that
any pernut(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie County Health Department to conduct necessary inspections to deternune compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or staking the hous acility location,proposed well location and the location of any other amenities.
5ite Revisit Charge
Pro ty o ier's or owner's legal representative signature
Date(s):
_��� Client Notification Date:
Date EHS:
3igr,given ❑Yes ❑No � Account# �,Z?�
Revised 1ll0�� . Invoice# �Zk _
• � , DAVIE COUNTY HEALTH DEPARTMENT
� . � Environmental Health Section
Soil/Site Evaluation ��_�,���
APPZICANT,.IN��A��'�ON Tax PIN/EH#: 5860-3�lB�RTY INFORMATION
Billed To: Mike Cook Subdivision Info: Baltimore Trails Lot# 10
Reference Name: Location/Address: Baltimore Trails-27006
Proposed Facility: Residence Property Size: 10 Acres Date Evaluated: �� 4—d�
Water Supply: On-Site Well � Community Public
Evaluation By: Auger Boring � Pit Cut
FACTORS . 1 2 3 4 5 6 7
Landscape position �,.,
Slope %
HORIZON I DEPTH _ �.
Texture grou G S G G
Consistence •r �+f p n,
Structure C P yA
Mineralo ';;�c� ; .�
HORIZON II DEPTH .
Texture rou S C
Consistence
Structure
Mineralo � �� C
HORIZON III DEPTH
Texture rou
Consistence �
Structure
Mineralo � �
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE '1 . .1 .�? �
SITE CLASSIFICATION: � �: > � EVALUATION BY: N�
LONG-TERM ACCEPTANCE RATE: • ,-- �' ( �� OTHER(S)PRESENT: �/�/I�� �/ (G�l�
REMARKS:
LEGEND
T,andsca�e 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
.ONSI�T .N .F,
11�ist '
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
�
NS -Non sficky SS -Slightly sticky S -Sticky VS -Very Sticky
NP-Non pla'stic 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
Mineraloev
1:1,2:1,Mixed
1�otes
Horizon depth-In inches
, . Depth of fili-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)
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