199 Lakewood Dr Davie County,NC • � T�Parcel Report ���� Tuesday, October 4,2016
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WARNING: TffiS IS NOT A SURVEY
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Parcel Information
Parcel Number. K50000001001 Township: Jerusalem
NCPIN Number: 5737827027 Municipality:
Account Number. 69938000 Census Tract: 37059-807
Listed Owner 1: SPILLMAN KENNETH M Voting Precinct: SOUTH MOCKSVILLE
Mailing Address 1: 199 LAKEVI/OOD DRNE Planning Jurisdiction: Davie County
City: MOCKSVILLE 2oning Class: DAVIE COUNTY R-A,R-20
State: NC Zoning Overlay:
Zip Code: 2702&2114 Voluntary Ag.District: No
Legal Description: 51.715AC LAKEWOOD VILLAGE Fire Response District: JERUSALEM,MOCKSVILLE
Assessed Acreage: 52.35 Elementary Schooi Zone: MOCKSVILLE
Deed Date: 5/1991 Middle School Zone: SOUTH DAVIE
Deed Book 1 Page: 001590232 Soil Types: MrC2,MrB2,Gn62,GnC2,EnB,GaD,ChA,WATER
Plat Book: Fiood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Buflding Value: 89840.00 Outbuilding 8�Extra 42340.00
Freatures Value:
Land Value: 290390.00 Total Market Value: 422570.00
Total Assessed Value: 197910.00
0�.�vl�, All data Is provlded u b wNhout wertaMy or guuaMee of any Idnd either e:pressed or implted InGuding but not Iimlted to tt�e
Davie County� ImpUed wartantles of inerchaMability or fitr�ma fw a particular usa All users of Davle CountYs GIS webslte shdl hold harmless the
7�T(� CouMy oi Davle,NoRh Grolina,its agerrta,co�nultants,contractors or employees hom any and a8 claims or auus ot actlon due to
��U N'� 1�`-' or arlsing out of fhe use or inabipty to use the GIS dah provided by Mls webska
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�C�aee,� ,,l y.�-.,� DAVIE COUNTY HEALTH DEPARTMENT l/��
Name:- ��.�f�'� �'l�.�` s::�.:'.f.� ',.:- Environmental Health Section PROPERTY INFORMATION
� P.O.Box.848
`Directions to property: . � .:�'-�" �''�� ,.�����`_�-f���r^'� Mocksville,NC 27028 Subdivision Name:
,r ..,,.. ;:� �. r ' Phone#: 336-751-8760
Cr'j. .,,-v,.� ..�<' �✓ ��/�:'7,�l�T�i�� Section: Lot: �
.J �' AUTHORIZATION FOR
�,f�,f.r WASTEWATER Tax Office PIN:#S�7 r �S'2'` �a '3�7
SYSTF,M CONSTRUCTION
AiJTHORIZATIONNO: �,�e�' � � A `'� RoadName: Zip:
**NOT'E**This Authorization for Wastewater System ConsWction MUST BE'ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts.This Fomi/Authorization Number should be presented to the Davie County Building Inspections
' Office when applying for Building Permits. • :
(ln compliance with Artide 11 of G.S.Chapter I30A,Wastewater Systems,Section:1900 Sewage Treatment and Disposai Systems)
�"/ r �j �~'"' e �,, ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
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���°�,��.��'`���''"� ��. � '� .
r � , } C• (�� ' IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED � '
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RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEllROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE . �!(#PEOPLE'� #PEOPLE/SHIFT� #SEATS ��!INDUSTRIAL WASTE:Yes or No. ;
LOT SIZE TYPE WATER SUPPLY��'��L :DESIGN WASTEWATER FLOW(GPD)p.�r�.� NEW SITE REPAIR SITE jG , '
/��"� �Q �U'�..5
SYSTEM SPECIFICATIONS: TANK SIZE GAL..PUMP TANK GAC. TRENCH WIDTH /.-�1_� ROCK DEPTH ''� LINEAR Ff.�
..,--. ' -"i..
', OTHER � ....
' REQUIRED SITE MODIFICATIONS/CONDITIONS: - '
IMPROVEMENT PERMIT LAYOUT, - �
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�� . : �070.� � :
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"*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 THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT _
_ SYSTEM INSTALLED :
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AUTHORIZATION N0. OPERATION PERMIT BY: DATE: �-'l'�L� `�`�
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA'FE THA'T THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTTH ARTICLE I 1 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.
ncr,o oa�oz c���s�a� � � oa� 5.--d �
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, . DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT(REPAIR)
NAME �`.O PHONE NUMBER
ADDRESS_/�� �' // �CJ� SUBDIVISION NAME
�9�%����/ C°- LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED � / AME SYSTEM INSTALLED UNDER �°��� �✓J- �l �'N'a�-�-�
TYPE FACILITY y NUMBER BEDROOMS�i� NUMBER PEOPLE SERVED
TYPE WATER SUPPLY f.�v��� SPECIFY PROBLEM OCCURRING
DATE REQUESTED ���6��� INFORMATION TAKEN BY ����./�
, This is to wrtify that th�i�fotmation provid�d is comd to the best of my knowledgs,and that I und�raWnd I am nsponsible}or eii charpss incuned from this applicetion.
SIGNATURE OF OWNER OR AUTHORIZED AGENT '��- �
iisv.1/93
, DAVIE COUNTY HEALTH DEPARTMENT
• � -� '�"� ' � Environmental Health Section
, _ P.O.Boa 848/210 Hospital Street �� ��—�3
Mceksville,NC 27028 ��
, (336)75]-87C►0
IMPROVEMENT/OPERATION PERMIT
Account #: 990002550 Tax PIN/EH#: 5737-82-7027
Billed To: Kenneth Spillman Subdivision Info:
Reference Name: Location/Address: Lakewood Village Rd-27028
Proposed Facility: Residence Property Size: 50 +acres
ATC Number: 3341
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People #Bedrooms #Baths
Dishwasher: ❑ Garbage Disposal: ❑ Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: �
Commercial Specification: Facility Type �i/ #People� #People/Shift_� #Seats Industrial Waste: ❑
Lot Size Type Water Supply ,.6/ Design Wastewater Flow(GPD)_,//,� Site: New�Repair❑
i� �/ .
System Specifications: Tank Size�GAL. Pump Tank GAL. Trench Widtt�� Rock Depth� Lmear Ft. �
Other: J
Required Site Modifications/Conditions:
INIPROVEMENT/OPERAT[ON PERMIT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF 6`�BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Deparhnent for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day of installation. Telephone#is(33G)751-8760.****
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Environmental Health SpecialisYs Signature: Date: /�(p�Q3
DCHD OS/99(Revised)
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� ' DAVIE COUNTY HEALTH DEPARTMENT
' � Environmentai Heaith Section
r.o.sog sasnio x�P���sr��t
� Mocksville,NC 27028
(33G)751-8�60
Account #: 990002550 Tax PIN/EH#: 5737-82-7027
Billed To: Kenneth Spillman Subdivision Info:
Reference Name: Location/Address: Lakewood Village Rd-27028
Proposed Facility: Residence Pro ert Size: 50+acres
ATC Number: 3341
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER C NSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: G�L[ Date: ��,Fj �,3
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
�
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Septic System Installed By: ��' �
Environmental Health Specialist's Signature: i � Date: �`����-UZ
DCHD OS/99(Revised)
�
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' APPLICATION FOR SITE EVALUATION/IMhROVEMENT PERMIT&AT � �
e Davie County Health Department � �O n�
Environmenta/Hea/th Section �% �S'
P.O. Box 848/210 Hospital 5treet Q��+
Mocksville, NC 27028 �� ZO
(336)751-8760 02
�i,p�N� 4
***II�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE
INFORI�TION IS PROVIDED. Refer to the INFORI�TION BUZLETIN for instruction�ry��
1. Name to be Billed ����� ��/ �/ i. /, Contact Person
�lQq A '�C—
Mailinq Address / [ L ��2��'G(��BC�' ��. Home Phone��3�p �f51—,j���
City/State/ZIP /"/QC , //����. /(I� �.?�Z� Busiaess Phone,���-`j� �z�S
2. Name on Permi.t/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: f�Site Evaluation '�mprovement Permi.t/ATC Both
f j '
a. system to service: ❑ House ❑ Mobile Home �Business ❑ Industry � Other
5. If Residence: N People # Bedrooms # Bathrooms
O Dishxasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing f1 Basement/No Plumbing }
6. If Business/Industxy/Other. Specify type 'i ` # People � # Sinks �
�k Commodes T A Shoxers # Urinals _� . # Water Coolers
IF FOODSERVICE: # Seats _�/�� Estimated Water Usage �gallons per aay)
7. Type of water supply: ❑ County/City � Well ❑ Com�unity
a. Do you anticipate additions or expansions of the facility this system is intended to serve? �Yes ❑No
_ j
If yes,what tyPe? �'�/,.t��e vl
K
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: �Q���' WRITE DIRECTIONS(trom Mocksville)to PROPERTY:
Tax Office PIN: # �� � ���"� �O�-� ��!� ��� .
� '
Property Address: Road N��S��u/nnd /"=��J`��r�' G�
City/Zip�b���S !/•�/P ��/-�!
lf in a Subdivision provide information,as follows:
Name: ��� /—C
—� •
Section: Block: Lot: Date Property Flagged: (���R� �;,�_..J
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issucd hercafter 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 tl:at I am tesponsible for aU clrurges incurred from
� this application. I,hereby,give consent to the Authorized Representative of the Davie County Health Department
to cnter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine thc site suitability.
. �
DATE I�' 2U —p z SIGNATURE ����.l�ia
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLA1�I(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, �nd septic locations).
� �� ��. �d� ���,L� �—�t,�� Site Revisit Charge'
�r.:�_�,�-�-- � Datc(s): •
--� �� Clicnt Notification Date.
. CJ�`�— j� EHS:
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S�- ���""� _
Account No. �5�
Revised CHD(07/99) � � Invoice No. ��—�� L�
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�' • � . • DAVIE COUNTY HEALTH DEPARTMENT
` • .° �'• + Environmentcal Health Section
� . � Soil/Site Evaluation
APP�.TCANT INFORMATION PROPERTY INFORMATION
.
Account #: 990002550 Tax PIN/EH#: 5737-82-7027
Billed To: Kenneth Spillman Subdivision Info:
Reference Name: Location/Address: Lakewood Village Rd-27028
Proposed Facility: Residence Property Size: 50+acres Date Evaluated: �—�'"��
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition
Slo e%
HORIZON I DEPTH / ` �1
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH / � �'
Texture rou
Consistence '
Structure ' / -
Mineralo
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo �
HORIZON N DEPTH
Texture rou `
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE ,
SITE CLASSIFICATION: � EVALUATION BY: �Y,ri ��
LONG-TERM ACCEPTANCE RATE: . � OTHER(S)PRESENT:
REMARKS: �C.. � �
ND �
L na dscape Position.
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Tenace 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
Mineraloev
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-gaUday/ft2
DC�-ID OS/99(Revised)
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