191 Camellia LnDa�ie County, NC Tax Parcel Report Wednesday, October 12, 2016
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Parcel Information
Parcel Number: F300000095 Township:
NCPIN Number: 5820579938 Municipality:
Account Number: 29076750 Census Tract:
Listed Owner 1: GHOLSON AMY Voting Precinct:
Mailing Address 1: 191 CAMELLIA LANE Planning Jurisdiction:
City: MOCKSVILLE Zoning Class:
State: NC Zoning Overlay:
Zip Code: 27028-0000 Voluntary Ag. District:
Clarksville
37059-801
CLARKSVILLE
Davie County
DAVIE COUNTY R-A
Legal Description: 9.010 AC OFF DANNER RD Fire Response District: WILLIAM R. DAVIE
Assessed Acreage: 9.03 Elementary School Zone: WILLIAM R DAVIE
Deed Date: 10/1999 Middle School Zone: NORTH DAVIE
Deed Book / Page: 003170809 Soil Types: PcC2,RnD,ChA,CeB2
Plat Book: Flood Zone:
Plat Page: Watershed Overlay:
Building Value: 44410.00 Outbuilding & Extra
Freatures Value:
Land Value: 55600.00 Total Market Value:
Total Assessed Value: 100010.00
DAVIE COUNTY
100010.00
No
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�,\'/ All data Is provided as is without warranty or guarentee of any kind eithar expressed or implied including but not limited to the
9 �",° F Davie County� Implied warranties of inerchantability or fitness for a particular use. All users of Davie Countys GIS website shall hold harmless tha
County of Davie, North Carolina, its agents, consultants, contractors or emp�oyees (rom any and all clalms or causes of action due to
�O�,�yq" NC or arising out of the use or Inability to use the GIS data provlded by this websitc.
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� AUT�CQ��[�A'�'ION No. O �% O DAVIE COUNTY HEALTH DEPARTMENT `' '�� �sN�"����ti �_-
-- ' Environmental Health Section PROPERTY.���11�1TION ,3 : 3�
Permitte ' . � .�.. ' P.O. Box 848 �
Name: '�1M 1�0. 1� �1� ���R� �D `�`ti Mocksville, NC 27028 Subdivision Name:
\ Phone #: 704-634-8760
Directions to property: �-,�' i�� '��. \�'x� Section: Lot:
AUTHORI7ATION FOR
�~> ;, .c . r� -'_'�� �e�.. � t.-�` Gr. � c,4r� ��'�11'•: rJ�SYSTEM CO TRUCTION Tax Office PIN:# � r�.��,b - `: � - ��=
O�, �'.�.�r��. . Road Name: � Zi � 0� `�
P�
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Buiiding Permits. This Forn�/Autfiorization 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
�� �`N .,�, <;-`_`,�::a�� �• �:,.. }�.1�;�-:a ' � . . IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED , �
rr ,� ,
a -; ' , �;- � � ` ���a�
�� ��� ,z; � ��,� , ' DAVIE �COUNTY HEALTH DEPARTMENT � l' �' `"' � .. , ^�,�'
---}c. ;. `�� ,: IMPROVEMENT-AND OPERATION PERMITS PROPERTY OR1�TION 2. 3�
Pernutt�~S ✓ _,,� � � � r � � > .
1!t .i .�., �..
4 I1lanie: � f'�:: t�� !� 6�'� t� �� 1'R1 4D P� Subdivision Name:
. .-
D'uections to property: 4 y� ''� `�, �`t� � Section: Lot:
, .
.;� IlVIPROVEMENT �
��� � n , ^i� i,.. `t z .. � ^ `>.,3, > PERMIT Ta�c Office PIN:# r `- � ! =' - ' i - i .� t
� , ,�-- �^ , � RoadName:�,--'_;,_,��'��Zip: h E:„'`I
**NOTE** This Improvement Pernut DOFS NOT authorize the construction or installation of a septic tanlc system or any wastewater sysEem. An
' u AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/'mstalladon of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTTCE*** TfII.S PERNIIT IS SUBJECT TO REVOCATION IF SITE
,' ', _, _ � _ � � ��:, ° � `�� ��';�$ ; PLANS OR THE IlVTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSiJ�D . SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING Tf� SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
i
COMMERCIAL SPECIFICATION: FACILTTY TYPE � # PEOPLE S� # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or�
LOT SIZE C�.c �^_ TYPE WATER S[jPPLY �"� DESIGN WASTEWATER FLOW (GPD) � t` � NEW SITE � REPAIR SITE
y ~� 1 1i / �
SYSTEM SPECIFICATIONS: TAN SIZE �� UGAL. PUMP TANK GAL. TRENCH WIDTH .~) ROCK DEPTH � LINEAR FT. (���� n
(� '''(' �
OTHER `o �Via�.�. \ VSc�;•....
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REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
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s
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^„'_-----� �� _„�,
r
**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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
I OPERATION PERMIT
kv
Fv
j ,. SYSTEM INSTALLED BY: � �.wl�X�-
�v�N / 9�
� .� .
AUTHORIZATION NO.�/ `�� OPERATION PERMIT BY: DATE: ��1 � 1�
**THE 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 SATISFACTORII,Y FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department � � ��
Environmental Health Section �' ��, � ��� p
P. O. Box 848 �� L
Mocksville, NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �W►A � �� b � A11 Contact Person �
Mailing Address (�� eA LVIP L ��, �Q„h � Home Phone % O �i �� a. � g��
City/State/Zip �� � S� ��t I( P , n�.�,'1(�2� Business Phone 7� � `i 35b �
2. Name on PermidATC if Different than Above
Mailing Address `S' A {� City/State/Zip
3. Application For:
4. System to Serve:
5. If Residence
� Site Evaluation
❑ House ❑ Mobile Home
# People
❑ Improvement Permit & ATC
i� Business
# Bedrooms
❑ Industry ❑ Other
# Bathrooms
�Both
❑ Dishwasher ❑ Garbage Disposal �� Washing Machine ❑ Basemen lumbing ❑�a� ent/No Plumbing
, /►� � � �.� b
6. If Business/Other: Specify type �,� I.F.Lre � People G # Smks
,,,� ,� �ri�.
# Commodes # Showers # Urinals /f� # Wat�Coolers
—� —� —'fL— �
If Foodservice:
7. Type of water supply:
# Seats
❑ County/City
Estimated Water Usage (gallons per day) � S �
i� Well
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community �
❑ Yes �No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
�� �� o( /`�L SUBMITTED WITH THIS APPLICATION.
' �-t"
Property Dimensions: � G -�� Q- � � e`�`� i W E D I R E C T I O N S ( from
� 3/�� � Moc ksvi l le) T O P R O P E R TY:
Tax Office PIN: # s$o� - � Z - 7 3 7`� � �Q' �o r�'h (�QS� �' ��
/� �J�� 1
Property Address: Road Name 1-/1 �lIC/!/vc Q�/1e � .
, � R�4 h� oh�e,r�ner�d.
c�cy�z�p U 1 ��G a-��� '
i �r. � oYl ,�3 N1 P� L�l a iat.�
If in Subdivision provide information, as follows: 1
� (�'o �o �hd o� IroA�
Name: �
I
Section: Lot #: �
I
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 inforrnation submitted in this application is
falsified or changed. I, also, understand that I am responsible for all charges incuned from this application. I, hereby, give consent to
the Authorized Represe�tative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by
as necessary to determine the site suitability.
DATE I �� `� � �C� SIGNATURE
Revised DCHD (06-96)
conduct all testing procedures
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� � .' . � ' DAVIE COUNTY HEALTH DEPARTMENT
.- ' Environmental Health Section SECTION LOT
� SoiUSite Evaluation
APPLICANT'S NAME DATE EVALUATED �-t. �� J l v
PROPOSED FACILITY ���l ��g� PROPERTY SIZE �� �-�-�
SUBDIVISION ROAD NAME �: P�`z\�1'E� hA N�
Water Supply:
Evaluation By:<, �, �
On-Site Well
Auger Boring
' Community,
� Pit
Public
Cut _
n�ri «�rmurrrc.c.
SITE CLASSIFICATION: � �S•
LONG-TERM ACCEPTANCE RATE: ��
REMARKS:
DCHD (01-90)
EVALUATION BY: C��.,o�-� ���'�-9.
OTHER(S) PRESENT: N �� �'
���-...-�.. ��,�.�� � 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
Moist
VFR - Very friable
Wet
NS - Non sticky
NP - Non plastic
FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
SS - Slightly sticky S- Sticky VS - Very Sticky
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
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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. � . �avie County �CeaCth �epartment
" and�.�-Come .�L�eaCth �t.gency
( �nvironmentaC.�Cealth Section
� P.O. BOX 848 / 21O HOSPITAL STREEf �(
COURIER::09-40-06
MocKsvt�LE, N.C. 27028
PHONe: (704) 634-8760
December� 2d, 1996
Ir�agination Statian
Attn: Amy Gholsan
191 Camellia Ln.
Mocksville, NC �7��'8
RE: Site Evaluation/C�r�ellia Ln.
Tar, Office RIN: #JB��—J.T—%37L
Dear Client:
As requested� a repr,esentative fr�ar� this office visited1 the
aforementioned site on De�ember i9, 199b, aasEd upon the inforr�ation
provided on the applic�tion for, site ev�Iuation and after the evaluation
was completed, the site was found to be provisionally suitable for� the
inst�llation of �n on—site sew��ge dispos�l system.
.
If you h�ave any questions, please feel free to cantact this office.
� Sincerely, � '
C; ��� �.
Charles E. Little, R.S.
Environmental Nealth Section
CEL/wd
Enclosur,e (s)
STATE OF NORTH CAROLINA
AGREEMENT CONCERNING SEPTIC
SYSTEM
COUNTY OF DAVIE
This Agreement for Water Access (hereinafter "Agreement") is made this the � day
of�, 2007 by and between P&R REAL ESTATE INVESTMENTS, LLC and AMY
GHOLSON and husband, BRUCE GHOLSON
WITNESSTH:
Wf-�REAS P&R Real Estate Investments, LLC is the owner of the property located at
• 205 Camellia Lane, Mocksville, North Carolina, 27028, as more particularly described in Deed
Book 738, Page 0038 in the Davie County Register of Deeds (hereinafter the "P&R Real Estate
Property") and
WHEREAS, the Gholsons are the owners of the properly located at 191 Camellia Lane,
Mocksville, North Carolina, 27028, as more particularly described in Deed Book 317, Page 809
and adjoins the Property; and
WHEREAS, during a recent survey of the P&R Real Estate property it was discovered
that the septic system to the P&R Real Estate property infringes over the property line of the
Gholsons; and
WHEREAS, P&R Real Estate does not want to move the septic system, even if possible,
and desire to have the septic system remain infringing on the Gholson's property as it has existed
over previous years; and
WHEREAS, P&R Real Estate is desirous of reaching a mutual agreement with the
Gholsons that provides for a continuing septic system.
�� THEREFORE, for P&R Real Estate Investments, LLC, their heirs, successors and
assigns and for the Gholsons, their heirs, successors and assigns, the parties agree as follows:.
1. The Gholsons agree to allow P&R Real Estate to keep the septic system as it exists in
its current state on Gholsons property at no expense to the Gholsons.
2. P&R Real Estate agrees to pay for any costs or expenses associated with repair or
maintenance of said septic system.
3. The parties agree that this Agreement shall be perpetual or until an alternate septic
system is made available to the P&R Real Estate property.
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4. The parties agree to notify the other party if ar,y repair or maintenance is required and
the timing thereof.
IN WITNESS WHEREOF, the parties have caused this Agreement to be duly executed as
of the date first written above.
P&R REAL ESTATE INVESTMENTS, LLC
BY: �,�„��r�� (Seal)
TITLE �r�s� oe��- M ��,ac, �12
;
�.� (Seal)
AMY GH SON
��"�t,te�e. (Seal)
BRUCE GHOLSON
STATE OF NORTH CAROLINA
COUNTY OF �Ors' �
I hereby certify that the following person(s) personally appeared before me this day each
acknowledging to me that he or she voluntarily signed the foregoing document for the
purpose stated therein and in the capacity indicated: PHILIP CROUSE, MEMBER-
MANAGER OF P&R REAL ESTATE INVESTMENTS, LLC,
DATE: \a- di1—O�
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(Seal) �
STATE OF NORTH CAROLINA
COUNTY OF v �W
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Signature of Notary Public
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Printed Name of Notary Public
My Commission Expires: �-1 �i "� l�
I hereby certify that the following person(s) personally appeared before me this day each
acknowledging to me that he or she voluntarily signed the foregoing document for the
purpose stated therein and in the capacity indicated: AMY GHOLSON AND BRUCE
GHOLSON.
DATE: I a.- �,��� �
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NOTE THIS PLAT IS SUBJECT TO ANY EASEMENTS.
AGREEMENTS OR RIGHTS-OF—WAY PR[OR TO THE
DATE OF iHIS PLAT, WHICH 1NERE NOT YISIBLE AT
THE TIME OF MY INSPECT[ON.
DECLARATION [S MAOE TO THE ORIGINA�
PURCHASER OF THE SURVEY. [T IS NOT
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TDYINSHIP COUNiY STA7E DAiE JOB N0.
CXARKSVILLE DAVIE NC 10-19-07 2007138
BEING A BOUNDARY SURVEY OF THE PROiPERTY DESCRlBEO IN D.B. 572,
G. 32bL ALSO KNONN AS TAX PARCEZ 5820671378.
McAnally- Land Surveying, P.C.
1001 S. Marshall St 8ox 84 Vlfinston—Salem, N.C. 27101
Phone � 336-631-9805
sc.�i� �' — 40�
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