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337 Jamestowne DrApplicant: Ronald W. Shaver Address: 337 Jamestowne Drive City: Mocksville State2ip: NC 27028 Phone #: (336) 998-6381 Address/Road #: Subdivision: 337 Jamestowne Drive Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 2 # of People: 2 "Water Supply: EXISTING WELL Property Owner: Ronald W. Shaver Address: 337 Jamestowne Drive City: Mocksville State2ip: NC 27028 Phone #: (336) 998-6381 Phase: Lot: Directions Hwy 64 East, left on Comatzer Rd, left on Jamestowne Drive System Specifications Pump Required: OYes ONo O May Be Required Nitrification Field 7 3 $ Sq. ft. Pump Tank: Gallons No. Drain Lines 1 1 -Piece: OYes ONo Total Trench Length: 8 3 GPM—vs— ft. TDH Trench Spacing:9 OInches O.C. Dosin Volume: _ Gallons — Feet O.C. g Trench Width:Inches — 3 2 Feet Grease Trap: Gallons Aggregate Depth: inches PreTreatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: OI Oil 0111 OIV Dann i ^f 'A Minimum Trench Depth: a 4 Site Classification: Provisionally Suitable Inches Saprolite System? OYes ONo Minimum Soil Cover. 1 a Inches Design Flow: 2 4 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 . 3 a 5 Maximum Soil Cover: a 4 Inches 'System Classification/Description: 'Distribution Type: GRAVITY SERIAL TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: _ Gallons 'Proposed System: 25% REDUCTION 1 -Piece: OYes ONo Pump Required: OYes ONo O May Be Required Nitrification Field 7 3 $ Sq. ft. Pump Tank: Gallons No. Drain Lines 1 1 -Piece: OYes ONo Total Trench Length: 8 3 GPM—vs— ft. TDH Trench Spacing:9 OInches O.C. Dosin Volume: _ Gallons — Feet O.C. g Trench Width:Inches — 3 2 Feet Grease Trap: Gallons Aggregate Depth: inches PreTreatment: ONSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: OI Oil 0111 OIV Dann i ^f 'A CDP File Number 193019 - 1 County ID Number: 1-16-000-00-082-06 ❑ Open Pump System Sheet Kepalr z5ysiem Kequlreo:%V r rs vivo vivo, mut nds rnvdudurtn Opdcor /Repair System Trench Spacing: Q Inches 0. *Site Classification: Provisionally Suitable Feet O.C. Trench Width: 0 Inches Design Flow: a 4 0 — , 3@ Feet Soil Application Rate:0 3 a 5 Aggregate Depth: inches *System Classification/Description: Minimum Trench Depth: a 4 Inches TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6 Inches *Proposed System: 25% REDUCTION Maximum Soil Cover. a 4 Nitrification Field 7 3 $ Sq. Inches f#. No. Drain Lines a *Distribution Type: GRAVITY -SERIAL Total Trench Length: 1 $ 4 f Pump Required: DYes ONo OMay Be Required Pre Treatment: ONSF OTS -1 OTS -II , *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department *Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Penni; not to exceed five years, and maybe Issued at the same time the Improvement Permit Issued (NCGS 130A-336(b)� If the installation has not been completed during the period of validity of the Construction Permit, the Information submitted In the application for a permit or Construction Authorization is found to have been Incorrect, falsified or changed, or the site is altered, the permit or Const;=tlon Authorization shall become Invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance; monitoring, reporting and repair (1938(b)). ApplicantlLegal Reps. Signature Required? QYes ONO Applicant/Legal Reps. Signature: Date:. . . *ssued By: Date of Issue: 2140 - Nations, Robert 0 3/ 1 7/.1 0 1 6 I..._.._._.... . Authorized State A Malfunction Log QYes @Hand Drawing 01mport Drawing **Site Pian/Drawing attached.** Page 2 of 3 • CONSTRUCTION AUTHORIZATION • Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: 193019 -1 County File Number: 1-16-000.00-082-0e Date:0 3/ 1 7/ 0 1 6 Q Inch Scale: QBlock Q N/A I J bl�I I I UrA I i �c I �� - II III Cl- OtA CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P O 8 848 CDP File Number. 193019 -1 .. ox County File Number: H65 -000-00-08e-01 Mocksville NC 27028 Date: .0.3 / 1 7/2016 Click below to Import an Image from an external location: Drawing Type: Construction Authorization 1 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT &ATC Davie County Environmental Health pA�- = (P.O. Box 848/210 Hospital Street , - `� Mocksville, NC 27028 �0to ; (336)753-6780/Fax (336)753-1680 1L000�`roab ' plication For: � Site Evaluation/Improvement Permit C Author' tion To Construct (ATC) ❑ Both Type of Application: ❑New System ❑Repair to Existing System xpansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name n o c� Address City/State/ZIP Email Contact Person Home Phone /� f Business Phone Name on Permit/ATC if Different than Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners F1a2Qed NOTE: A survey plat or site plan must accompany this application. Included: LJ Site Plan LJPlat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name 6^a Phone Number Owner's Address 25Y 1 City/State/Zip Property Address City Lot Size Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is "Yes",supporting d cumentation must be attached: Are there any existing wastewater systems on the site? es No Does the site contain jurisdictional wetlands? 7C o _Yes Are there any easements or right-of-ways on the site? _Yes _ gg Is the site subject to approval by another public agency? _Yes `1Vo Will wastewater other than domestic sewage be generated? _ Yes _4io IF RESIDENCE FILL OUT THE BOX BELOW # People C2-- # Bedrooms# Bathrooms. Garden Tub/Whirlpool I IYes INo Basement: :]Yes ❑No Basement P umbing: IYes :]No 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: EZnventional ❑Accepted ❑Innovative ❑Altemative ❑Other. Water Supply Type: C County/City Water 0 New Wellsting Well :1 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? C 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 locating and flagging or s the houle�/facili to tion, proposed well location and the location of any other amenities. dr' " t-,�"' ( 4 -A -+ -, Site Revisit Charge P7p�rty owner'ss order's leg representative signature Ar -c2 �17 1 Client Notification Date: Date EHS: Sign given I Yes ❑No Account # Revised 11/06 Invoice # '�SWF-s• Applicant: Address: City: CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: x336-753-1680 Ronald W. Shaver1 337 Jamestowne Drive Mocksville State/Zip: NC 27028 Phone #: (336) 998-6381 / For Office Use Only *CDP File Number 193019 - 1 County ID Number: H6-000-00-082-06 Evaluated For: NEW township: PERMIT VALID UNTIL: 05/04/a0.10 Property Owner: Ronald W. Shaver Address: 337 Jamestowne Drive City: Mocksville State/Zip: NC 27028 Phone #: (336) 998-6381 n & Site Information Address/Road M Subdivision: 337 Jamestowne Drive Mocksville NC 27028 Directions Structure: # of Bedrooms: # of People: *Water Supply: OTHER /3e GC't/7�([i �q Hwy 64 East, s�fi �- e 8 h 4 S� #W,0A— Drive / EXISTING WELL ns Phase: Cornatzer Rd, left ,� l��GlrZo om Lot: mestowne Classification: Provisionally suitable Minimum Trench Depth: a 4 Inches \Site Saprolite System? OYes ($ No Minimum Soil Cover: —1a Inches Design Flow: 1 0 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 3.2 5 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY - PARALLEL (eq. d -box) TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons *Proposed System: CONVENTIONAL 1 -Piece: O Yes ® No Pump Required: O Yes ® No O May Be Required Nitrification Field 3 0 Sq. ft. Pump Tank: Gallons No. Drain Lines 1 1 -Piece: OYes ONo Total Trench Length: 1 0 a GPM --vs— ft. TDH ft Trench Spacing: — 9 Q R Inches O.C. Feet O.C. Dosing Volume: _ Gallons Trench Width: 3 Inches Feet _ Grease Trap: Gallons Aggregate Depth: 1 a inches Pre -Treatment: O NSF OTS -1 OTS -II Septic Tank Installer Grade Level Required: 01011 OIII 01V / Page 1 of 3 � .. CDP File Number 193019 - 1 County ID Number: H6-000-00-082-06 ❑ Open Pump System Sht-et rSvstem Required: ®Yes ONO ONO, but has Available Space *Site Classification: Provisionally Suitable Design Flow: 1 0 0 Soil Application Rate: 0 3 a 5 *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: CONVENTIONAL Nitrification Field No. Drain Lines Total Trench Length 3 0 7 Sq. ft. 1 1 0 aft. Trench Spacing: 9 O Inches 0. — ® Feet O.C. Trench Width: — @Inches 3 Feet Aggregate Depth: 1 a inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover: 1 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches *Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required: OYes O No O May Be Required Pre -Treatment: O NSF OTS -1 OTS -11 *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rema �n9 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Characters 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and may be issued at the same time the Improvement Permit issued (NCGS 130A -336(b)). If the Installation has not been completed during the period of validity of the Construction Permit, the information submitted In the application for a permit or Construction Authorization is found to have been Incorrect, falsified or changed, or the site is altered, the permit or Construction Authorization shall become Invalid, and may be suspended or revoked (.1937(g)). The person owning or controlling the system shall be responsible for assuring compliance with the laws, rules, and permit conditions regarding system location, Installation, operation, maintenance, monitoring, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? O Yes ONO Applicant/Legal Reps. Signature- Date: *Issued By: 2140 - Nations, Robert Date of Issue: 0 5 / 0 4 / a 0 1 5 Authorized State Agent: Malfunction Log OYes (9) Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 .W , CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: County File Number: 1-16-000-00-082-06 Date: 05 /04/.1015 O Inch Scale: O Block O N/A Page 3 of 3 P1 P2 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: P.O. Box 848 H6-000-00-082-06 Mocksville NC 27028 County File Number: Click below to import an image from an external location Date:.0.5./.0 4./...0.1.5. Drawing Type: Construction Authorization Page 3 of 3 P1 P2 Phone: (336) - 753 - 6780 Davie County Health Department Environmental Health Section P.O.. Box 848 • 1 � r 210 Hospital Street Courier #: 09-40-06 ; Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 /Name:/� G� �L�Gy�� Phone Number, Mailing Address: 33 7 Y&ft1-11do0,h E fir. (Work) /�%�✓ v✓l% /UL . �2 702/ Email Address: Detailed Directions To Site: /Y�y U L'G✓'f te)Rd Adr/0 IS -174 r &, c✓-/ou//' f ,br — V Property Address: L,,PTease Fill In The Following Information About The EXISTING Facility: Name System.Installed Under: 13A aa J%4 vC-✓ Type Of Facility: /Vo//i E nJ, *E Date System Installed (Month/Date/Year): Number Of Bedrooms: .2. Number Of People: ;- Is The Facility Currently Vacant? Yes If Yes, For How Long?. Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Infjor®mation About The NEW Facility: Type Of Facility: D� .(3yi /o'i dt� ,90 Y 3 0 Number Of Bedrooms: AdA C Number of People JUo/Wl Pool Size: M16' / Garage Size: ILMNE Other:_J h /'G4 6� Requested By: /G� �V Date Requested: OG7` (Signature) For Environmental Health Office Use Only Comments: Environmental Health Specialist *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 #: D _Invoice #: ' / 7 / (jJ(t t t� "Pr7X " URVV Printed:Oct 09, 2014 All data is provided as is without warranty or guarantee of any kind either expressed or Implied including but not limited to the implied warranties of merchantability or fitness for a particular use. All 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 or arising out of the use or Inability to use the GIS data provided by this website. Appraisal,Card —ER RONALDIV K W—/A ppMI NOtM: PI—Ml N6-000-00-032-06 37MMEMWNE DR PUT: 11/209 UNIQ ID 13610 4657680 ID NO: 5759607766 COUNTY TAX (100), FIRE TAX (100) GRD N0. 10 1 w41 YMr: 2012 Tax Y— 2015 19.33 AC OFF CORNATZER RD (18.250 AC) 18.250 AC13.250 AC SRC. In9pMUen nl Mdd 17-10/07/201307001 S MADY GROVE TW -07 Cl. FR -05 E%- AT- LASTACTION 20140123 CONSTRUCTION DETAIL MARKET VAW[ DEPRECIATION CORRELATION Of VAW. OTAL POINT V LU BU2WING USE MOD Area QUAL MTE RCX EYB AYB REDEN CE TO AD]USTMFNTS 9 0 % OOD EPR. BUILDING VALUE• GRD OTALADIUSTMENT TYPE: ACTOR V.—tEPR.OB/XF VALUE -GRD RMFT VMO YALYS•GRD 4,910 106,]60 OTAL QUALITY INDEX STYLE; OTAL MAR MET VALU!-GRD W.70 07" APPRAISED YAW! -GRD 111,6]0 DIAL APPRAISED VALU-PARCEL 111,670 DIAL PRESENT US& VAW!-PARCEL OTAL VAW! DEFERRED • PARC9L OTAL TAXABLE VALU! • PARCEL PR[ A 111,670 VALUE 16,070 B%F VALUE BBXIVAL I,S00 ND VALUE 109,250 RESENT USE VALUE IC EFEAREO VAWE CODE DATE NOTE NUMBER EK AMOUNT OUT: WTRSHD: SALES DATA F !CORD AlE D!!D INDIGT! SAM AG R TVP! U 1 P", HEATED AREA NOTES PUT Ol RGS UNiT ORIG M CONO LDGR YSM AMN DEP RATE % DDND OB/XF DEFR VALUE RPL DE ESCRIPTION OUN T MI PRICE _ Ol3 Ola 5 10 1500 B H SITE 1,500.00 IRFPUCE l RAGE I'll 1 10.00 979 979 5 UMRG I CAGE A I RAGE 9 10.00 0.00 _ 988 986 988 966 5 5 2 2 160 45 UILDING DIMENSIONS NOINFORM TION TMER D]USTMENT5 IGNEST ND NOTES LAND TOTAL NEST S! USE D! LOCAL —"GTAG! "OR YFPTH / !ITN SI2[ LND MOO COND fACT RP AC LC OT TO OA TYPE UNIT PRIG[ LAND UNIT TOTAL UNITS TY AD]tT AD"" D UMR►RIC[ LAND OVERBID[ GND VALY! YAWS NOTES H H MESIT 0201 0 .0140 4 0.6200 1 -1 r -10 0 00.00 1.50 A 0.629 ,649. 0 10675 0 00 DTAL MARKET "ND DATA 16.250 106,760 OTAL PRESENT USE DATA Ion a�a s✓Gl. 10e -Z--, Owner• SHAVER RONALD W Page 1 of 1 http://66.226.39.229//ITSNet/AppraisalCard.aspx?parcel=H60000008206 10/9/2014