901 Joe RdHEALTH DEPARTMENT RELEASE
Davie County Health Department
210 Hospital Street
' P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Nelson Jones
Address:
477 Joe Road
City:
Mocksville
State/Zip:
NC 27028
Phone #:
(336) 998-3879
Address901 Joe Road
Road # Mocksville
*Structure: SINGLE FAMILY
# of Bedrooms: 2
*Water Supply: PUBLIC
Basement: ❑ Yes ❑ No
*Proposed Improvement:
Replace home
NC 27028
# of People:
PERMIT VALID 0 1/ a 9/ a 0 a 0
UNTIL:
Property Owner: Nelson Jones
Address: 477 Joe Road
City: Mocksville
State/Zip: NC 27028
Phone M (336) 998-3879
Property Location & Site Information
Subdivision: Phase: Lot:
arpiatairr5 foot setback to any portion of the septic system
hl 0i OI 10
Township:
Directions
Hwy 64 E. right on Joe Road, Property on left just past Cedar Creek
Rd.
Type of Business:
Total sq. Footage: No. Of Employees:
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? OYes O No
Applicant/Legal Reps. Signature: *Date: /
*Issued By: 2140 - Nations, Robert *Date of Issue: 0 1 a 9 a 0 1 5
Authorized State Agent:
**Site Plan/Drawing attached.**
(& Hand Drawing O ImportDrawing
Characters
Remaining
691
Davie County Health Department
U is�36rt` Environmental Health Section
4 P.O. Box 848
r 210 Hospital Street
r'p ItECE1VED Courier : 09-40-06
Mocksville, NC. 27028
Dsa:
Phone: (336) - 753 - 6780
ON-SITE WAS CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name:. WC150yi�C}y�C? S Phone Number Z5 ,j q (Home)
Mailing Address: 4-7 7 �Y6C, egad -,5-U 7 _q(Work) (,
WQJG.5 0i V e, C_ Q 6,-4-S - Email Address:
Detailed Directions To Site: 404 m-6 + -4-6 . de Ra a A- (ijrn ri q {,-}-
cS� r 061'0 V
Property Address:
. IeS- AJ,,,;
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: �� Type Of Facility: M a 6 i (e, R -t m &
Date System Installed (Month/Date/Year): Q kr e ul n Number Of Bedrooms:_Number Of People: C�'
Is The Facility Currently Vacant? es No If Yes, For How Long? r--5
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: J fJ (Yt 4Joi (f, �\Dy►xP Number Of Bedrooms: Number of People
Pool Size: VIOn arage Size: �A _ - Other:
Requested By: Date Requested:_�l /V1
-5—
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*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 - tiec Money Order # Amount:$ Date:
Paid By: Al, Nis Received By: c.
Account #: Invoice #:
All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied
(W 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.
�4Zj
0UN�
Printed -Jan 21, 2015
Exhibit "A"
TRACT I: Lying and being in Fulton Township, Davie County, North
Carolina, and beginning at an established iron pin, said
established iron pin being the Northwest corner of Duke Power
Company in the Southern line of R. Nelson -Jones and wife, Jane S.
Jones, Deed Book 108, Page 170, Davie County Registry; thence south
02° 39' 31" West 176.40 feet to a new iron pin; thence North 740
30' 44" West 294.03 feet'to'a new iron pin; thence South 890 00'
00" West 200.00 feet to a new iron pin; thence South 560 00' 00"
West 186.28 feet to a new iron pin located in the eastern right-of-
way of No Creek Road, SR #1808; thence with said right-of-way North
400 38' 39" West 37.75 feet with the chord to a point; thence North
20° 00' 00" West 41.35 feet to a point; thence North 32' 30' 00"
West 66.00 feet to a point; thence North 43° 00, 00" West 66.00
feet to a point; thence North 650 00' 00" West 201.93 feet to a
point; thence North 520 23' 27" West 42.34 feet to a new iron pin
in the'line of R. Nelson Jone's and wife, Jane S. Jones, Deed Book
108, Page 170, Davie County Registry; thence South 850 30' 00" East
984.73 feet to the POINT AND PLACE OF BEGINNING and containing 3.00
acres, as surveyed by Francis B. Greene, Registered Surveyor, on
September 10, 19'85.
TRACT II: Lying and being in Fulton Township, Davie County, North
Carolina, and beginning at an existing iron located on the right-
of-way of No Creek Road NCSR #1808, said existing iron being the
southwest corner of Thomas D. Dornatzer, Deed Book 128, Page 151,
Davie County Registry, and being a southern corner of Gary D.
Flippin, Deed Book 128, Page 250, Davie County Registry, and being
on the northern right-of-way of said road and being 26.5 feet to
the center line of said road; thence North 49° 54' 20" West 438.87
feet to an existing iron, said existing iron being a southern
corner of R. Nelson Jones, Deed Book 108,Page 170, Davie County
Registry; thence South 52° 23' 27" East 42.34 feet to an unmarked
point; thence South 65° 00' 00" East 201.93 feet to an unmarked
point; thence South 43° 00' 00" East 66.00 feet to an unmarked
point; thence South 32° 30. 00" East 66.00 feet to an unmarked
point;- thence South 20° 00, 00" Bast 41.35 feet to an unmarked
point; thence South 40° 34, 00" East 37.76 feet to an existing
iron, being the POINT AND PLACE OF BEGINNING, and containing 0.272
acre, as surveyed by Hall's Land Surveying Company, January 27,
1986.
. BK.325P bbl9
EXHIBIT `A'
TRACT I: Lying Ind Tieing in Fulton Township, Davie County, North Carolina, and
beginning at an established iron pin, said established iron pin being the Northwest
corner of Duke Power Company in the Southern line of R. Nelson Jones and wife,
Jane S. Jones, Deed Book 108, Page 170, Davie County Registry; thence South 02
degs. 39 min. 31 sec. West 176.40 feet to a new line; thence North 74 degs. 30
min. 44 sec. West 294.03 feet to a new iron pin; thence South 89 degs. 00 min. 00
sec. West 200.00 feet to a new iron pin; thence South 56 degs. 00 min. 00 sec.
West 186.28 feet to a new iron pin located in the eastern right of way of No Creek
• Road, SR #1808, thence with said right of way North 40 degs. 38 min. 39 sea West
37.75 feet with the chord to a point; thence North 20 degs. 00 min. 00 sec. West
41.35 feet to a point, thence North 32 degs. 30 min. 00 sea West 66.00 feet to a
point; thence North 43 degs. 00 min. 00 sec. West 66.00 feet to a point; thence
North 65 degs. 00 min. 00 sec. West 201.93 feet to a point; thence North 52 degs.
23 min. 27 sea West 42.34 feet to a new iron pin in the line of R. Nelson Jones
and wife, Jane S. Jones, Deed Book 108, Page 170 Davie County Registry; thence
South 85 degs. 30 min. 00 sec. East 964.73 feet to the POINT AND PLACE OF
BEGINNING and containing 3.00 acres, as surveyed by Francis B. Greene,
Registered Surveyor, on September 10, 1985.
TRACT 11: Lying and being in Fulton Township, Davie County, North Carolina, and
beginning at an existing iron located on the right of way of No Creek Road NCSR
01808, said existing iron being the southwest corner of Thomas D. Cornatzer,
Deed Book 128, Page 151, Davie County Registry, and being a southern corner of
Gary D. Flippin, Deed Book 128,
Page 250, Davie County Registry, and being on the northern right of way of said
road and being 26.5 feet to the center line of said road; thence North 49 degs. 54
min. 20 sec. West 438.87 feet to an existing iron, said existing iron being a
southern corner of R. Nelson Jones, Deed Book 108, Page 170, Davie County
Registry; thence South 52 degs. 23 min. 27 sec. East 42.34 feet to an unmarked
point; thence South 65 degs. 00 min. 00 sea East 201.93 feet to an unmarked
point; thence South 43 degs. 00 min. 00 sea East 66.00 feet to an unmarked
point; thence South 32 degs. 30 min. 00 sec. East 66.00 feet to an unmarked
point, thence South 20 degs. 00 min. 00 sec. East 41.35 feet to an unmarked
• point; thence South 40 degs. 34 min. 00 sec. East 37.76 feet to an existing iron,
being the POINT AND PLACE OF BEGINNING, and containing 0.272 acre, as
surveyed by Hall's Surveying Company, January 27, 1986.
THIS COVEYANCE is made pursuant to N.C.G.S. 39-13.3 O for the purpose of
severing the existing tenancy by the entirety and conveying the property above
described in fee simple to Grantee. It is further intended and agreed that this
conveyance is made pursuant to the provisions of N.C.G.S. 52-10 and G.S. 29-
30(a)2 to extinguish any claim by Grantor of any marital interest in the above-
described property, which shalt henceforth be the sole and separate property of
the Grantee, and to extinguish any present or future claims of Grantor for
equitable distribution which may arise under N.C.G.S. 50-20 et sea.
0
GE=996 ' Dv
WARRANTY D Pam WD•d01 Printed and for age by James Williams"Ind.,Yadkirir�Wt
STATE OF NORTH CAROLINA, Davie County.
THIS DEED,mode tb4 dayot ,19by andti.ew.en Dwight Shuler and wife,
_Frances Shuler of _Davie
County .
and sure of North Ca-olina,hereinafter called Cantor,and Gary Dean Flippin and wife, Wanda B. Flippin
of Davie County and Sure o(Nonh Carolina,hereinafter
called Grantee,whose permanent mailing address is
WITNESSETHI Thit the Grantor,for and In eonaldustbn o(tbe am of?en dnI l Ar nnA Oyr------------------------=Dollar&
and other good and valuable considerations to him in hand paid by the Granite,the receipt wherso(6 hereby acknowledged,has given,muted,bargained,sold
and conveyed•and by these presents does give,grant,bargain,sell•convey and confirm unto the Grantee,his heirs and(or sucectsm muted,
premises N
rUjtQn Township, Davie County,North Carolina,described as(allows
Lying and being in Fulton Township, Davie County, North Carolina and beginning
at an established iron pin, said stablished iron pin being the Northwest corner
of Duke Power Company in the Southern line of R.Nelson Jones and wife, Jane S.
Jones, Deed Book 108, page 170, Davie County Registryy -thence South 02 degrees
39 minutes 31 seconds West, 176.40 feet to a new iron pins thence North 74 degrees
30 minutes 44 seconds West, 294.03 feet to a new iron pin; thence South 89 degrees
00,minutes 00 seconds West, 200.00 feet to a new iron pint thence South 56 degrees
'00 minutes 00 seconds West, 186.28 feet to a new iron pin located in the eastern
tight of way of No Creek Road,.SR 01808; thence with said right of way North 40•
degrees 38 minutes 39 seconds West, 37.75 feet with the chord to a pointtthence'
North 20 degrees 00 minutes 00 seconds West, 41.35 feet to a point; thence North
32 degrees 30 minutes 00 seconds West, 66.00 feet to a points thence North 43
degrees 00 minutes 00 seconds West, 66.00 feet to a pointy thence North 65
degrees 00 minutes 00 seconds West, 201.93 feet to a pointy thence North 52
degrees 23 minutes 27 seconds West, 42.34 feet to a new iron pin in the line of
R.L. Nelson Jones and wife, Jane S. Jones, Deed Book 108, page 170, Davie County
Registryy thence South 85 degrees 30 minutes 00 seconds'East, 984.73 feet to the
POINT AIDPLACE OF BEGINNING and containing 3.00 acres as surveyed by Francis B.
Green's Registe)red Surveyor on September 10, 1985.
liOf.iNA f NOR I�ROt_INA
FZgC$4.00
MdL esTATtt
GIPM TAX .l [XCtnt TAX
50 i
The above land was conveyed to Grantor by .See Book No. ,Pape
TO HAVE AND TO HOLD The above described premises,with all the appurtenances thereunto belonging•or in any wise appertaining,unto she Grantee,his
heirs and/or success",and assigns forcer.
And lite Grantor covenants that he is seised of said premises in.fee,and has the tot to convey the same In(ae simple;that mW premises are(tee flat*tet-
cumbrances(with the exceptions above stated,I(any):and that he will we r t a at and defend the said title to the Same against site lawful claims of all persons
whansaever.
When reference is made to the Grantor or Grantee,the since shall Include the plural and the masculine shall include the feml ine or the neuter.
IN WITNESS WHEREOF,The Grantor has hereunto set his hand and seal,the day and first stove wrh)Jn.
(SEAL) (SEAL)
(SEAL) •(SEAL)
STATE OP NOR C 4.ROLINA COUNTY. ,�.jt�n
I. g u er an w e, rance6aSnu�e`><blieo(Said County,dohercbycertify tht! Y^u Grantee.personally appeared before me this day and acknowledged the execution of the foregoing ed. .9kr7
Witness my hand and notal seg,this the r `day of '(;
My Commission Expvtu `e49 (
STATE OF NORTH CAROLINA COUNTY.
a Notary public of uid County,do hereby certify that
Grantor,personally appeared before me this day and acknowledged the execution of the foregoing deed.
Witness my hand and notarial seal•this the. day of
My Commission Expirev, ,N.P.ISEAL I
STATE OF NORTH CAROLINA, niSViA _ COUNTY.
The foregoing certil'rcate(*of Linda p• learlaM• N. p, of navieL_Camty
Is goq certified to be correct.This instrument was presented for registration this 7• .. day of Oct abs
at_1W5 A.M.,0M.,and duly recorded In the office of the Register of Deed&a(- County,
North Carolina,In Book 128 ,Page 250 .
Thh the 2 day of O .A.D.,19ILL.
T- K-fiBiih By
Register of Ikeda A sunt,NNW Register of Deed&
This Deed drawn by d!Lft o .14 ([rOe/A C p ,, A=narn'l a j Owe
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934198)) Permit Number
\ Name-- `yam/- Date
Location
r ^
Subdivision Name J Lot No. - Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms _ No. Baths _ No. in Family
Garbage Disposal YES ❑ NO ❑. . Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES p NO -❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
_
i
Improvements permit by —
*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 day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by,.",
i
Certificate of Completion 'r �f-� Date f _
*The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
/ SOIL/SITE EVALUATION
Name , �/�/ Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
UU U U
4) Soil Depth (inches) S S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space /v S. S S
PPS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described byTitle Date
SITE DIAGRAM
Y
DCHD(6-82)
2
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department '
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Business Phone
2. Address lif
3. Property Owner if Different than Above ��!—(�h o jc N
Address a � N o c.kSvi � it. W1 C� X7D2?
4. Permit To: a) Install Alter Repair
b) Privy - Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home ✓ Business
IndustryOther .)o J b
b) Number of people L "
6. a) If house o obile ho , state size of home and number of rooms.
House Dimensions 2 x 5
Bed Rooms_Bath Rooms—Den w/Closet_
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals Nome garbage disposal 0 h e-
lavatory showers Z washing machine
dishwasher 1 sinks
8. a) Type water supply: Public P•rivateCommunity
b) Has the water supply system been approved? Yes._,, No
9. a) Property Dimensions 'q• 4e-res
b) Land area designated to building site ac Ce.
c) Sewage Disposal Contractor_W h 1?a W/a 4-A Dr A2
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? �
What type?
This is to certify that the information is correct to the best of my knowledge. _
Date Owner SignVtffre
OWNER IS SOLELY RESPONSIBLE FOR COM LIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5,�ays or processing
Directions to property:
i --n
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v
IJ.? Le r 6 vt �
4e
.�21 wvllrc'�
C'
h
DCHD(6-82)
A,
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY:.Soe Booe Rd. DATE RECEIVED
L)Av 1k 00un4,Lj (office use only)
Roy
yes Dno 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent fromb 6/i yl e i- , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system. .
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
ri g'gs�
DATE SIGNATU
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
Owners designated representative
Anyone requesting results
Only those listed below
X7.28-BS .
DATE SIGNATURE
DCHD(11/84)