139 Stone Wood Rd Lot 4 Davie County,NC Tax Parcel Report Friday, December 30, 2016
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WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number: M4050B0004 Township: Jerusalem
NCPIN Number: 5736505226 Municipality:
Account Number: 82518538 Census Tract: 37059-807
Listed Owner 1: AMMERMAN JEFFERY ALLEN Voting Precinct: COOLEEMEE
Mailing Address 1: C/O HABITAT FOR HUMANITY Planning Jurisdiction: Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay: DAVIE COUNTY CZOD
Zip Code: 27028-0000 Voluntary Ag.District: No
Legal Description: LOT 4 GLADSTONE WOODS Fire Response District: COOLEEMEE
Assessed Acreage: 0.72 Elementary School Zone: COOLEEMEE
Deed Date: 6/2010 Middle School Zone: SOUTH DAVIE
Deed Book/Page: 008280938 Soil Types: GnB2
Plat Book: 0007 Flood Zone:
Plat Page: 073 Watershed Overlay: DAVIE COUNTY
Building Value: Outbuilding&Extra
Freatures Value:
Land Value:' Total Market Value:
Total Assessed Value:
101
All data is provided as Is without warranty or guarantee of any idnd either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use.Ail users of Davie County's GIS website shall hold harmless the
County of Davie,North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to
NCor arising out of the use or inability to use the GIS data provided by this website.
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Account #: 990005383 Tax P€N!EH#: 5736-50-5226
Billed To: Habitat for Humanity of Davie County Subdivision Info: Gladstone Woods Lot#4
Reference Name: LocationlAddress: 139 Stone Wood Lane-27028
Proposed Facility: Residence Property Size: .724 Acres
ATC Number: 5011
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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. /
System Type: -EKS.T.Manufacturer 62-1Z Tank Date(STank Size
Pump Tank Size
System Installed By: E.H.Specialist: Date: ( /
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f�-
DCHD 11/06(Revised)
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 #: 990005383 Tax PINIEH#: 5736-50-5226
Billed To: Habitat for Humanity of Davie County Subdivision Info: Gladstone Woods Lot#4
Reference Name: LocationrAddress: 139 Stone Wood Lane-27028
Proposed Facility: Residence Property Size: .724 Acres
ATC Number: 5011 Site Type:OKew ❑Repair ❑Expansion
**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 3 #Bathrooms#People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size CCCunty/Type of Water Supply: oCity ❑Well ❑Community Well
2 D
System Specifications: Design Wastewater Flow(GPD) 3 �crank Size X GAL.Pump Tank GAL.
ell r/
Trench Width Max.Trench Depth �i Rock Depth)=f�F Linear Ft.J �0
Site Modifications/Conditions/Other: As stated in 15A NCAC 181.1969(5)
ceoeptud Systemsy also be use
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760.
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^�^ tads _
E ironm ntal Health Specialist Date:
DCHD 11 6( evised)
4 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 #: 990005383 Tax PiNIEH#: 5736-50-5226
Billed To: Habitat for Humanity of Davie County Subdivision Info: Gladstone Woods Lot#4
Reference Name: LocationiAddress: 139 Stone Wood Lane-27028
Proposed Facility: Residence Property Size: .724 Acres
ATC Number: 5011 Site Type: Rr<ew ❑Repair ❑Expansion
**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-3 #Bathrooms D,#People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
' Square Footage(or Dimensions of Facility)
.Lot Size 11.7 "7 QCrt Type of Water Supply: ?'County/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow(GPD) 3&OTank Size GAL.Pump Tank GAL.
Trench Width 3 L Max.Trench Depth 1 Rock Depth.0 Linear Ft.3(Do
Site Modifications/Condi5A
As stated in 1NCAC 18A.1969(5)
tions/Other: `
ay also 56 used.
Contact the Davie County Environmental Health Section for final inspection of this system between
8:30—9:30a.m.on the day of installation. Telephone#(336)751-8760.
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Environme tal Health Specialist / Date:
DCHD 11/06(Revised)
Davie County Environmental Health
P.O.Box 848%210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax(336)753-1680
IMPROVEMENT PERMIT
a
Account #: 990005383 Tax PIN/EH#: 5736-50-5226
Billed To: Habitat for Humanity of Davie County Subdivision Info: Gladstone Woods Lot#4
Address: P.O. Box 1384 Location/Address: 139 Stone Wood Lane-27028
City: Mocksville,
Property Size: .724 Acres
Reference Name:
Proposed Facility: Residence '
**NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system.',,An v
Authorization To Construct a wastewater system must be obtained from this office prior to the i!
construction/installation of a wastewater system or the issuance of a building permit(in compliance with`fy
Article 11 of G.S. Chapter 130A,Wastewater Systems). This Improvement Permit is subject to
revocation if site plans,plat or the intended use change.:°w {i
Permit Type: Aew ❑Repair ❑Expansion Permit Valid for: SP1 Years ❑No Expiration
Residential Specifications: #Bedrooms 3 #Bathrooms__.2 #People Basement❑ Basement plumbing❑
Non-Residential Specifications: Facility Type #People #Seats
2// Square Footage(or Dimensions of Facility)
Design Flow(GPD): JCQ� Type of Water Supply: 6County/City ❑Well ❑Community Well
Site Modifications/Permit Conditions:
As stated in 15A NCAC 18A.1�J69(5�
asoer�trd Systems may bo us a
-System Type LTAR
Initial r .'O'n
Repair � � ' ' d •7,
Site Plan
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E vironmental Health Specialist Date
i.p.11-06
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax(336)75.1-8786
Application For: ❑ Site Evaluation/Improvement Permit Authorization To Construct(ATC) ❑ Both
Type of Application: XNew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORNATIOI�'IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed Ha�r�a� {ar �u»Zgni ay' Contact Person Lnl7 e,L r�de,Phfm
Billing Address PO Go)( 133 4 Home Phone
City/State/ZIP a r,Jrsv;ll e.. /VC 27O2? Business Phone (336) 751-7515
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name "i -or v ni avie-G,, Phone Numbe 36 '751-75!5
Owner's Address M P City/State/Zip /JOSV/LLQ c 2702
Property Address 139 S}-one.wawd gvte, CityMods-v lle,
Lot Size .79q-acres Tax PIN# 5Z5&-0-517Z(-
Subdivision
Z5&-0D5ZZ(-
Subdivision Name(if applicable) C-1aas4one. Lyoods Section/Lot#
Directions To Site:
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)kNo
Does the site contain jurisdictional wetlands? ❑Yes XNo
Are there any easements or right-of-ways on the site? ❑Yes o
Is the site subject to approval by another public agency? ❑Yes No
Will wastewater other than domestic sewage be generated? ❑Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People #Bedrooms 3 #Bathrooms 2 Garden Tub/Whirlpool ❑Yes XNo
Basement: ❑Yes )INo Basement Plumbing: ❑Yes NNo
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: #Seats
Type system requested:. Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ( County/City Water ❑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?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(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 determine 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 house/facility location,proposed well location and the location of any other amenities.
/� a Site Revisit Charge
Property owner's or owner's legal representative signature
Date(s):
/2Z ZQ 9 Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# 3
Revised 11/06 Invoice# 116,
W li.
151• ` , OOWC CU
1s SARAH NOLLEY C
C6 p8 D.B.38 PG.206 C
S 64�3Tp C
#2 1SS4'4ST44) C
4 34 f \ C
C
- C
?a°' / 104 p0 0<'�F� C1.
LOT #3 G,�o� C1
(0.720 AC.) 39
132,pp (396,0
14
oLOT #5
(0.748 AC.) LOT #
o 6
(0.690 AC.) � 2 a
LOT #7
.. N id (0.698 AC:)
1, `f/
75 00
#15 I i �'pJ �/� 222.35 TOTAL) 135.00 - --
53 AC.) i j �C11 ry 76-491S6,
CS
EA5EMIENT CIO` S 76'49,56. C4 n lj.
-120.00_ 222.35 TJDrAI)
_;/ •,�z'°�e LOT #14 i/ c. ca
(1.29
a 9 AC.) �
4 LO
2 LOT #12
(0.762 AC.) 4J L 11
0.736 AC.
o `� o
zfu
N o LOT #�.
_ 8 a (0 944 AG�
I _
i Z yk`
236.19 +
120.99 156.35
N 84.09104' Y
NE BEARING DISTANCE (915.48 TOTAL)
q.
Ll S 04'19'21" W 84.93 ,+
L2 S 2508'44' W 180.37
0 S 0730'20* W 23.46
L4 S 07.3020 W 80.45 SHIRLEY JONES
LS S 3322'31" W 31.61 e "
D.B.66 PG.206
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I, hereby certify that the subdivision plat shown a
with the Davie 1'
that we are the owners of hereon has been found to comply
n of
n and described hereon and County Subdivision Regulations with exceptio , 5•
dopt this plan of subdivision such variances, if any, as•are noted in',the
sent, establish minimum set— minutes of the Planning Board and it has been
idicate all streets, alleys, walks, approved for recording in the Office of Deeds.
sites and easements to public It is hereby noted that such approval for
noted. Futhermore, we hereby recordation does not include approval for the ti q
all sani sewer, storm sewer construction or occupancy of buildings or structures. `'�• &, � G �Y �t�ry k
�4
to vie C unty(if app licable)• 1 lf4
DIRE OR ;' e "
OWNER AVIE COUNTY PLANNING DEPARTMENT
GC! M/ y.
OWNER 1 A a 1 gat +4az moi,.
/ REVIEW OFFICER'S CERTIFICATE1 ,
I, John Gallimore, Revow 'atito whi hDavie
thisCcertfication
certify that the map P �xs
OWNER is affixed meets all statutory requirements for recording.
` •z�' .
Al
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GG �
-etDATE
f�
R OFFICER :
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http://maps.co.davie.nc.us/GoMaps/map/Index.cfm?mainmapservice=gomaps&CFID=41... 10/27/2009
- .'PLICATION FOR SITE EVALUATION/IMPROVEMENTPERMIT&AT , •
Davie County Health Department
Environmental Health Section JUL 2 1998
P.O.Box 848
Mocksville,NC 27028
(704)634-8760 ENVIRONMENTAL HEALTH
DAVIE COUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed �+ t' S W to P. C'no�J Contact Person
Mailing Address _` U oR� S� fie, Home Phone 2
City/StateMip o S,J\U 'L d �� Business Phone 75 �a a a rev
2. Name on Permit/ATC if Different than Above
Mailiag Address / City/State/Zip
3. ApplicE!ion For: O" Site Evaluation ❑ Improvement Permit&ATC ❑ Both
4. System to Serve: EI—House U-�Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms _ # Bathrooms
10 Dishwasher ❑ Garbage Disposal 01-Washing 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: El-'County/City ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes U—No
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions:�O6' x ?33.5. X X105.S',)a( 67199.Sa X 7 1? 1 WRITE DIRECTIONS(frons
1 Mocksville)TO PROPERTY:
Tax Office PIN: # .� 7 3(Q - '_� - _G k t-( f) 1
l 1 'F
Property Address: Road Name
1 -Eo N
City/Zip _1��c,��S.,���-P C_ 1 \
1 AcJSWwG `� c
1
If in Subdivision
��provide information,as follows: 1
Name:
1
Section:�5 �C-Ry- Lot #: 1
1
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 information submitted in this application is
alsified or changed.I,also,understand that I am responsible for all charges incurred from this application.I,hereby,give consent to
e Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
d owned by c ce o tpd. -Sr�We- d /"I i o conduct all testing procedures
necessary
to de/ttermine the site suitability.
ATE /-�-
SIGNATURE
evised DCHD(06-96)
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION_ LOT
Soil/Site Evaluation
APPLICANT'S NAME 0d/ DATE EVALUATED 710`%zl�'601
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION e!;�X7Z4C/0-11-/ ROAD NAME
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit f/ u Cut
FACTORS 1 e
7
Landscape position
Sloe%
HORIZON IDEPTH e•
Texture group -5 G.L C
Consistence D -
Structure 5 r►S w x
MineralogyJr- C
HORIZON 11 DEPTH 'S/ vfl,L-�>l V-Zlfr
Texture groupCIL C.
Consistence i 4
Structure /( ,S
Mineralogy = (0
HORIZON III DEPTH
Texture group
Consistence
Structure 6% o.y gu
Mineralogy D
HORIZON IV DEPTH
Texture group W
as
Consistence
Structure bac
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION 1A 5
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: 4 EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: / OTHER(S)PRESENT: JV tz
REMARKS:
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 I 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
DCHD(O1-90)