190 Hill Top Drlt!/1Li'1E?l,� 1'1:'5
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Phone: ,338? - 7,533 - 6780
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Davie County Ha.th Department
Environmental Health Section
R0, Box W
210 Hospital Street
Courier N.: 09.4M6
MocksviHe, NC 27028
ON -SM WASTEWATER CERTIFICATION FOR MULL
(Check One) Replacement Remodeling Reconnection
rf4ur_ al/UA:
inane Naarthe�r,,,,.
Itia,me•
Mailing Addrt&A: ("Work)
(/di 01 2Q4 Email
Detailed Directions To Site
Ptoperty Address:g� l • 0104c,Plasm Fill In The Following Inrornnation.About The RXIS.TING FRaility: 1' iw_ � o — D6 oFFOz-
:Varve System lnstalled I)nder:/N'� �� �G'�1�,71�/�(� Type Of Facility:_ �,fAW 0 IeW/� 4f
Daze System inetniled (Month/Dato/Yetir): �� ` a IS'uxnber Of Bedrooms: Number Of People:
Is The Fneility Currently Vacant? Yes (6 If Yes, For How Long?
Axny Known Problems? Yes leo If Yes, Explain:
Please Fill In The Following Information About The NEW F2VIlity:
' Typo Of Facility: � . _ _ _ Nvmber Of. adrooms: Munber ofPeopla
�( Requested By: --- Date Requested:— j? 0 )�
For Environmental Health Office, Use Only
Approved Dism5proved
En.vironrnental Health
Signing of this form by thb Envi;c:atnental HUM -Staff is
(extended or limited) that the on-site wastewater &ystcm t3
laic myt: Gaah Clteck ,vionV__ ...,rey uroer Amount:S
pard 13y; � �.-.,,.,,,,,,Date:
Account #:
3 J Received By:
---------------
--��_ TO 394d olflCSHII3M L6L88669EE1 5T:00 ETOZ/EZ/0T
/v
ro wa.y intended, nor should be taken as a guarantee
function properly for any glven period of time.
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LGL88669CET
91:00 EZOZ/EZ/0Z
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"CH6RIZ49TION NO: 114,6 6 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittees P.O. Box 848'
Name: 1 ' Mocksville, NC 27028 Subdivision Name:
/ r Phone #: 704-634-8760
Directions to property: /:/1 /��.4 lot _ . __��_� .. _ ._. Section: Lot:
\ :Y .� » » - - DAVIE COUNTY HEALTH DEPARTMENT
tom` MPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permltt�e s,,.) (�
Name: r %�� ;f Subdivision Name:
rV
Directions to property:]"/ . ,,7 tot Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:<�'-_
/ U1; Road Name: s � 1 og><:1! : Zip:
**NOTE** This Improvement Permit DOES authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WAS WATER SYSTEM CONSTRUCTION must be obtained,from this Department prior to the
construction/installation of a system or the issuance of a building permit. 11
(In compliance with Article 11 of G.S. Chaptei`�30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE 0,& # BEDROOMS . --L—# BATHS _,:2_ # OCCUPANTS _!� GARBAGE DISPOSAL: Yes or No _
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE �� TYPE WATER SUPPLY /i(/P/% DESIGN WASTEWATER FLOW (GPD) �&/-) NEW SITE `- REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE �QO GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH , � LINEAR Fr. G
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
**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. ON4HE15Ai;QF_1NSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED B
�,961,�9,40 � -
AUTHORIZATION NO. I OPERATION PERMIT BY: /46�1 DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE t
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.
1 DCHD 05/96 (Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Health Department 2 I� 15 2 O U2
Environmental Health Section D L5
P.O. Box 848 Nov 2
Mocksville, NC 27028 4 1997
(704) 634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �Il ¢ ✓ E/ d/5gj!Z_A:'04 �,J- Contact Person / e -2/cy/ a /?c4
Mailing Address W SJ go S, Home Phone 4147 2-5—
City/State/Zip ��o�tr�^/A� zfleL ;� 7o e C Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address 33; 5. City/State/Zip /��y,�.ve- If 70o G
3. Application For: [. ] Site Evaluation [ ] Improvement Permit & ATC [Both
4. System to Serve: [ ] House [,,- obile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People # Bedrooms # Bathrooms :2 [ ] Dishwasher [ ] Garbage Disposal
[&-IVashing 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 [ l Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [ ] No
If yes, what type?
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***)6dUSff OF THE PROPERTY MUST BE
�L SUBMITTED WITH THIS APPLICATION.
Property Dimensions. ' T ��� WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: # - - / �� G 4 Gia t3" to �¢! ,2c. �,y. /',� ate, .��/✓
Property Address: Roadame
II
City&ip :Ao%lay& e /V6. Z7oa6 ; ,tee . . qOP :, z <,J2
If in Subdivision provide information, as follows:
Name: ;
Section: 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
Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned
r
by i'Y4Q-\ �+ to conduct all testing prqpedures as necessary to determine the site suitability.
DATE -" -- 2-;7 SIGNATURE
OV
Revised DCHD (06-96)
THIS AREA MAY $E USEI) FOR DRAWING OUR SITE PLAN:
O
O
vim+ 01 e ,Z,l
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME ��1�,/� DATE EVALUATED `! ��
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION ROAD NAME
Water Supply: On -Site Well Community
Evaluation By: Auger Boring L__ Pit
Public
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L, L
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupCi
Consistence
/
Structure
C
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
c
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
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
Moist
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
Appraisal Card
DAVIE COUNTY. NC
Page 1 of 1
Jnr»lama �•�e•�rt ou
EAFORD JEREMY CRAIG Retum/Appeal Notes: LB -000-00-019-02
190 HILLTOP DR UNIQ ID 22321
3826000 D393 -P20 ID NO: 5776464743
COUNTY TAX (100), FIRE TAX (100) CARD NO. 1 of 1
eval Year: 2013 Tax Year: 2014 1.00 AC OFF RIVERVIEW RD 1.010 AC SRC- Inspection
Appraised by 07 on 08/02/2007 04002 CEDAR GROVE CHURCH TW -04 C- EX- AT- LAST ACTION 20130627
CONSTRUCTION DETAIL MARKET VALUE
DEPRECIATION -
CORRELATION OF VALUE
oundation - 3
Standard 0.2500
ontinuous Footin 8.0
ER
MO Area
BASE
UA RATE
RCN EYB AYB
REDENCE TO MARKET
US
ub Floor System - 4
lywood 11,00 02
1 02 1,6401101
43.86
293 199 199
% GOOD -1 75.0
EPR. BUILDING VALUE - CARD 54,70
xterior Walls - 30 TYPE: Manufactured Home (Multi) Manufactured Home
EPR. OB/XF VALUE - CARD 13
Iuminum in I Siding 32.00
MARKET LAND VALUE -CARD 16,97
wfing Structure - 03 STORIES: 1 - 1.0 Story
TOTAL MARKET VALUE - CARD 71,80
able 9.0
oofing Cover - 03
TOTAL APPRAISED VALUE - CARD 71,80
ksphalt or Composition Shingle 5.00
nterior Wall Construction - 5
TOTAL APPRAISED VALUE - PARCEL 71,80
)rywall/Sheetrock 28.0
nterior Floor Cover - 08
heet Vinyl/Laminate 7.0
OTAL PRESENT USE VALUE - PARCEL
nterior Floor Cover - 14
OTAL VALUE DEFERRED - PARCEL
OTAL TAXABLE VALUE - PARCEL 71,80
aet 0.00
eating Fuel - 04
PRIOR
Electric 1.00
UIIDING VALUE 63,92
eating Type - 10
BXF VALUE 220
eat Pump 5.00
AND VALUE 15,98
it Conditioning Type - 03
PRESENT USE VALUE
antral 5.00
DEFERRED VALUE
Brooms/Bathrooms/Half-Bathrooms
TOTAL VALUE 80,120
/2/0 0.00
L-0
PERMIT
LL - 0
LFUS-0
CODE DATE NOTE NUMBER AMOUNT
ASLL-0--""----------- 60_-----------------
ALUE 111.00 I B A S I
OUT: WTRSHD:
I 1
BUILDING ADJUSTMENTS 1 0
SALES DATA
3 AVG 1.000 I 1
FF'
INDICATE
Muali
a D.I 4 FACTOR 4 1.050 I + 5 - +
2 I W D D
ECORD ATE
DEED
SALES
OOK AGE R
ize 3 Size 0.880 7 1 1
TYPE
/
PRICE
OTAL ADJUSTMENT FACTOR 0.92 1 0 0
0202 415 1 5 119981
WD
U
V
OTAL QUALITY INDEX 10 1 + 5 - +
I I
I 7
I I
+ ----18----+--14---+-------2B-------+
HEATED AREA 1,606
4UOP 5
NOTES
+--14---+
/S BY OWNER
SUBAREA
UNITCE
ORIG %
ANN DEP
%
OB/XF DEPR.
RPL ODEDESCRIPTIO
T
NIT PRI
COND LDG B
AYB EYB
RATE V
GOND
VALUE
OOD FENCE01 01
Sol 8.701
01 1 L
119941199A
S51
1 301
131
TYPE GS AREA % CS 05
S 160 1001 7043grOTALOBIXF VALUE 131
OP 7 03 921
DD 5 021 S7
2 -rye
IREPLACE 1,00
Fabricated
UBAREA
OTALS 1,72 72,93
UILDING DIMENSIONS BAS=W60S27EIBUOP-S4El4NSW14S3 NIE14SIE28N7 WDD=E5N10W5S10 N20 .
NO INFORMATION
IGHESTTHER
ADJUSTMENTS
LAND TOTAL
NO BEST
USE
LOCAL
FROM
DEPTH /
LND
CO..
ND NOTES
OA
UNIT LAND UNT
TOTAL ADJUSTED LAND LAND
SE
CODE
ZONING
TAGE
DEPT
SIZE
MOD
FACT
RF AC LC TO OT
TYPE
PRICE UNITS TYP
ADIST UNIT PRICE VALUE NOTES
H HOMES ir
0201
30
0
2.4870
4
0.9800
02 +00 +00 +00 +00
RP
6,900.00 I.G09 AC
2.43A 16,815.30 1696
OTAL MARKET LAND DATA 1.009 16,970
OTAL PRESENT USE DATA
O
http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=L80000001902 10/22/2013