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5677 Hwy 801SDAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street - - • Mocksville, NC 27028 (336)753-6780/Fax #(336)753-1680 OPERATION PERMIT Account #: 990005809 Tax PIN/EH #: L700000005 Billed To: Tracie Williams Brack Beal Subdivision.lnfo: Reference Name: Location/Address: 5677 NC.HWY 801 S.-27028 Proposed Facility: Residential Property Size: 38.74 Acres ATO 4MU." T97s§uance 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: S.T. Manufacturer Tank Date Tank Size/ Pump Tank Size System Installed By: E.H. Specialist:A m —a''// ate:��2 GPS Coordinate: T� RY DCHD 11/06 (Revised) I 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 #: 990005809 Tax PIN/EH #: L700000005 Billed To: Tracie Williams Brack Beal Subdivision Info: Reference Name: LocationiAddress: 5677 NC HWY 801 S.-27028 Proposed Facility: Residential Property Size: 38.74 Acres - Site Type: U New ❑Repair ❑Expansion ATC Number: 5878 **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_ Basement❑ Basement plumbing❑ Non -Residential Specifications: Facility Type # People —# Seats Square Footage(or Dimensions of Facility) Lot Size Type of Water Supply: ❑County/City ❑ Well ❑Community Well System Specifications: Design Wastewater Flow (GPD)3(60 Tank Size- X60 GAL. Pump Tank GAL. Trench Width, lo�l Max. Trench Depth Rock Deptl�&� Linear Ft._3Q(` G S Site Modifications/Conditions/Other:(J' 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. CIO PJir i DCHD 11/06 (Revised) CK), 1 1 Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780 / Fax (336)753-1680 IMPROVEMENT PERMIT Account #: 990005809 Tax PIN/EH #: L700000005 Billed To: Tracie Williams Brack Beal Subdivision Info: Address: 435 Sanford Ave. Location/Address: 5677 NC HWY 801 S.-27028 City: Mocksville Property Size: 38.74 Acres Reference Name: PropQ_945TObft�?Ment 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 plans, plat or the intended use change. Permit Type: WNew ❑Repair ❑Expansion Permit Valid for: (15 Years ❑No Expiration Residential Specifications: # Bedrooms # Bathrooms2 t Z # People C7/Basement Basement plumbing 0' Non -Residential Specifications: Facility Type # People # Seats Square Footage(or Dimensions of Facility) Design Flow(GPD):30 - Type of Water Supply: Q County/City ❑Well ❑Community. Well Site Modifications/Permit Conditions: System Type LTAR Initial I1 -3 Repair WMILIftO Wi7m Site Plan F Is -�,� �b F 33►LAt I It MUUU U%/ Environmental Health Specialist Date i.p.l 1-06 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC - Davie County Environmental Health P.O. Boa 848/210 Hospital Street �j ®®' Mocksville, NC 27028 v (336)753-6780/ Fax (336) 753-1680 Applij i 217o ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) Both pe Apphc ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ••• s• THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED 1BT1-. INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Bi IW5tvii SM r9� Contact Person S calf S".r. •t'L. Billing Address 113 r" l t t— Home Phone City/State/ZIP)ikoeks.a11 c M.c- 7)tn 6 Business Phone '19 4 41 Name on Permit/ATC if Different thAboveTtpt, c %,a.\\c o« -% I tom. M04k Z-1.\ Ma ling Address A35 Sa rrutJ Lt. City/State/Zip ..\ C z PROPERTY INFORMATION *Date House/Facility Comers Flagged 2.8-4 20r NOTE: A survey plat or site plan must accompany this application. Included:.KSite Plan ❑Plat(to scale) (Permit r valid for 60 months with site plan, no expiration with complete plat.) Owner's Name pe{\ See;::,re A Phone Number Owner's Address City/State/Zip Property AddressS,71 r4. L O\ S Cityµ ticks.+\\ N • t_ Lot Size Tax PIN# wk o•F L700000 Subdivision ame(if applicable) Section/Lot# Directions To Site: 60( S `W BO 1 8 0 3 R ... o.. (1s - 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? &es ONo Does the site contain jurisdictional wetlands? ❑Yes bio Are there any easements or right-of-ways on the site? []Yes 2tio Is the site subject to approval by another public agency? XLyes fiNo Will wastewater other than domestic sewage be generated? ❑Ye No IF RESIDENCE FILL OUT THE BOX BELOW # People # Bedrooms : # Bathrooms z Garden Tub/Whirlpool ❑Yes MO Basement: ❑Yes Mo Basement Plumbing: ❑Yes o IF NON -RESIDENCE FILL OUT THE BOX BELOW Type ofFacilityBusiness 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: J]Conventional i7Accepted.3Innovative t Iterative 5Other Water Supply Type:County/City Water ❑ New Well ❑Existing Well C 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 comers and locat ng anc_IgGginZ4*-staking the house/facility location, proposed well location and the location of arty other amenities. Site Revisit Charge Property owner's or owner's legal representative signature Date(s): Z' �' /2 Client Notification Date: Date EHS: Sign given ❑Yes ONo Account# 519Z_ Revised 11/06 Invoice # C DP`W b7g • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/ Site Evaluation APPLICANT INFORMATION Account #: 990005809 Billed To: Tracie Williams Brack Beal Reference Name: Proposed Facility: Residential Property Size Water Supply: Evaluation By: PROPERTY INFORMATION Tax PIN/EH #: L700000005 Subdivision Info: Location/Address: 5677 NC HWY8011 S.-27 28 38.74 Acres Date Evaluated: _aO On -Site Well Community Auger Boring X Pit Public )� Cut SITE CLASSIFICATION: d�S LONG-TERM ACCEPTANCE RATE: 1 C ur'. ,rte EVALUATION BY:Ity 61J 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 3�'et 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 1:1, 2:1, Mixed >!ioto 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 05105 (Revised) - Landscape position Texture group Consistence Mineralogy HORIZON II DEM Texture - HORIZON groupTexture Consistence T2 M�3.01 iJI,''--�5 HORIZON IV DEPTH Texture group 11110 SOIL WETNESS (@]-,I • CLASSIFICATION SITE CLASSIFICATION: d�S LONG-TERM ACCEPTANCE RATE: 1 C ur'. ,rte EVALUATION BY:Ity 61J 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 3�'et 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 1:1, 2:1, Mixed >!ioto 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 05105 (Revised) - F LL L C_-1 1 1 I i LLL Aw t11 I!! �' I; 1 I �I - I ;moi-��%°l1'i- L L _( LL I L- i !__-moi `-_I I I I- I! i j ! j_1 -LLI IF F LL L —F FT� I Lo 1-11 —1 T II USE — .7 %i I _i- (+ F -1:1: -� I I (-i I F I_ _-rTl I-_ I -%Ii I F- 1 1—!_i-! T 1 I Ll --I �! _I I IFF�I ! it FFF— Fi—Fl FF 1 M—� 1 FIF i WL 777-1 F --�- �--- C FL - �- Davie County Health Department '0N31 N � nmental Health Sectionns - P.O. Box 848 210 Hospital Street Courier # : 09-40-06 1911 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON -SITE -WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Lin r —Q0,3j Phone Number / d �P � Home Names ��L1CI G �1 J j IRnI 5 S rQ�(— � L.(B-&0)473- ( ) Mailing Address: Jr SCl r rd Av C., (Work) Pk5yi � i g, JAG a700' Email Address: Detailed Directions To Site: L001 5 -Q C), +A"J,l Rol ( - 31r' � r �/ / a Property Address: 5� I 0�H1A! V CLQ 1 � • M� V I � I e , A/ C -Th are, 01 -ice Su.rvtA4 044:ra,c f 0.c 0,K-8'r#J 0"t o30-c.re, +ra) Please Fill In The Following Information Xbout The EMAING Facility: Name System Installed Under:Ann ( -6p(-for'i Type Of Facility: Date System Installed (Month/Date/Year): Sj or 99 Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? .s . No If Yes, For How Long? Any Known Problems? Yes If Yes, Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility:_Z Number Of Bedrooms: Q3 umber of People Pool Size: a a Size: Other: Requested By: e-101 Date Requested: (Signature) _ For Environmental Health Office Use Only Approve Disapproved �� //� '/ Comments: �� f-�/9/ C, n�/u�� P m.�cr/� /�vAr� ,fid /YZ.GG�" Environmental Health Specialist. Date: *The signing of this form by the Environmental Health Stfaff is in no way intended nor should be taken as a guarantee (extendeded) that the on-site wastewater system will function properly for any given period of time. Payment: Paid By:_ Account #: Order # Amount:$ Received By: Invoice #: Reports Davie County, NC Tak Parcel Report Page 1 of 1 *WARNING: THIS IS NOT A Monday, 1/30/2012 SURVEY!* 5766265109 This map is prepared for the 25328000 inventory of real property , ; ° A. oU found within this Jurisdiction, lk-11% and is compiled from recorded deeds, plats, and other public O APRIL RICHEE records and data. Users of this 066 EASTSIDE map are hereby notified that COURT the aforementioned public WINSTON-SALEM primary information sources NC should be consulted for 7127-0000 verification of the information 38.74 AC HWY 801 contained on this map. The P/0 LOTS 6-8 County and mapping company 38.68000000 assume no legal responsibility 979 for the information contained r001080640 on this map. Notes: Parcel Number: L700000005 PIN Number: 5766265109 Account Number: 25328000 Listed Owner #1: FERGUSON APRIL A SEAFORD Listed Owner #2: Mailing Address 1: O APRIL RICHEE Mailing Address 2: 066 EASTSIDE COURT it : WINSTON-SALEM State: NC Zip Code: 7127-0000 Legal Description: 38.74 AC HWY 801 P/0 LOTS 6-8 crea e: 38.68000000 Deed Date: 979 Deed Book and r001080640 Page: Plat Book: Plat Page: Building Value: 0 Outbuilding and Extra 500 Features Value: Land Value: 222700 Total Market Value: 227200 Total Assessed 227200 blue: http://maps.co.davie.nc.us/GoMaps/reports/report.cf m?CFID=85672&CFTOKEN=26682373 1/30/2012 •IL✓'I J/ Appraisal Card DAME COUNTY,. °me cl Page 1 of 1 1/26/2012 2:56:16 PM ERGUSON APRIL A SEAFORD L7-000-00-005 0 677 S NC HWY 801 UNIQ ID 22233 5328000 ID NO: 5766265109 COUNTY TAX,FIRE TAX CARD NO. 1 of 1 eval Year: 2009 Tax Year: 2012 38.74 AC HWY 801 P/O LOTS 6-8 38.710 AC SRC= Inspection m kppraised by 02 on 04/21/2008 05003 CHERRYHILL TW -05 C -EX -AT- LA ACTION 20100922 CONSTRUCTION MARKET VALUE DEPRECIATION CORRELATION m !VALUE DETAIL O TOTAL POINT Eff. BASE z ALUE USE MOD Area UAL RATE RCN TO n I 3 BUILDING JAYB-CREDENCE % x AD3USTMENTS 97 00 1 GOOD DEPR. BUILDING VALUE - r RD OB/XF VALUE - CAA > 4,50D]USTMENT TOTAL TYPE: Vacant RKET LAND VALUE - CA m 222,70ACTOR STORIES: TAL MARKET VALUE - Ci > � 227 20OTAL QUALITY TAL APPRAISED VALUE 0 ;ARD 227,20NDEX [EPR. TAL APPRAISED VALUE -ARCEL 227 20TAL PRESENT USE VALU • PARCEL TAL VALUE DEFERRED - 1RCEL TAL TAXABLE VALUE - F :CEL 227,20C PRIOI UILDING VALUE 3,80 BXF VALUE ND VALUE 187,22 RESENT USE VALUE DEFERRED VALUE OTAL VALUE V 191,020 PERM] CODE DATE I NOTE I fS. 1BER AMOUNT OUT: WTRSHD: �- SALES D. 4 o INDICATE o 'U ALES PRICcc: VI WHEA Ck SUBAREA ORIG ANN OB/ GSRPL UNIT % DEP % DEPR TYPE AREA / CS :ODE DESCRIPTION LTH WTH UNM PRICE COND BLDG L AYB EYB RATE IRCOND VALU IREPLACE Z4 SHED 20 50 1,OOC SAC 100 L 197 197 S' SUBAREA 2 MILK BARN 20 44 88C 19.0c 10 L 197 1970 S31 0 8 MH SITE 0 0 1 4,500.0 L 199 199 Sol 100 450 TOTALS OTAL OB XF VALUE 4,50C UILDING DIMENSIONS ND INFORMATION OTHER HIGHEST AD3USTMENTS AND AND NOTES LAND TOTAL AD3USTE BEST USE LOCAL FRO EPTH / LND COND RF AC LC ROA UNIT LAND UN OTA UNIT LAND LAND USE OD ONINGTAGEDEPTH SIZE MOD FACT TO OT TYPE PRICE UNITSTYPAD3ST PRICE VALUE OTE FR 0113 348 0 0.8940 4 D .990 06 +20 +25- PW ,500.0 38.713 AC 0.88 5,752.5 22269 LOOD RIVER 20-20 OTAL MARKET LAND DATA 38.713 22 70 OTAL PRESENT USE DATA http://maps.co.davie.nc.us/ITSNet/AppraisaiCard.aspx?parcel=L700000005 1/26/2012 Parcel #: L70000000503 Davie County, NC - Basic Estate Search 'Basic Search Real Estate Search Tax Bill Search Sales Search Q View Property Record for this Parcel View Map for this Parcel View Tax Bill Informatto0 Parcel #:L70000000503 Account #:8301388 Owner Information I Tax Codes ICHEE APRIL THERESA D..... & WILLIAMS TRACIE SEAFOR 1C ADVLTAX - COUNTY TA 066 EASTSIDE COURT IREADVLTAX - FIRE TAX INSTON SALEM NC 27127 28,47 Property Information Townshi Land (Units/Type): 2.091 JERUSALEM [Address: 5677 S NC HWY 801 Deed Information Local tonin Date: 07/2012 Book: 00897 Page: 0239 Plat Book: 11 Page: 79 Legal Description PIN 2.091 HWY 801 SOUTH 5766171265 Property Values Building: 154,93 BXF• Land: 28,47 Market: 183 40 ssessed• 183,40 Deferred: Sales Information No. Book Page Month Year Instrument Qual/UnQual Improved Price 1 00897 0239 07 2012 WD Unqualified Vacant 0 View Property Record for this Parcel View Map for this Parcel View Tax. Btlt Information « Return to Basic Search Page 1 of 1 riot, Davie County Web Site All information on this site is prepared for the inventory of real property found within Davie County. All data is compiled from recorded deeds, plats, and other public records and data. Users of this data are hereby notified that the aforementioned public Information sources should be consulted for verification of the Information. All information contained herein was created for the Davie County's internal use. Davie County, Its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or implied, in fact or in law, including without limitation the implied warranties of merchantability and fitness for a particular use. If you have any questions about the data displayed on this website please contact the Davie County Tax Office at (336) 753-6120. 1.5.9 http://maps.daviecountync.gov/itsneWiew.aspx?prid=1468293 8/24/2016