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135 Natalies WayHEALTH DEPARTMENT RELEASE d Ysr,o Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Terry G. Smith Address: 188 Centenary Church Road City: Clemmons State2ip: NC 27012 Phone M (336) 391-9976 r For Office Use Only *CDP File Number 121220 -1 B7-000-00-004 County ID Number: valuated For: HDR/WWC PERMIT VALID 0 4/ a a/ a 0 1 8 UNTIL: Property Owner: Terry G. Smith Address: 188 Centenary Church Road City: Clemmons State2ip: NC 27012 Phone M (336) 391-9976 Property Location & Site Information Address Natalies Way Subdivision: Road # Advance NC 27006 SINGLE FAMILY Township: 'Structure: Directions # of Bedrooms: # of People: See map *Water Supply: PUBLIC Basement: Yes ❑ No Proposed Improvement: Small Home Phase: Lot Type of Business: Total sq. Footage: No. Of Employees: It is the responsibility of the owner to maintain a 5' minimum setback between the wastewater system and any part of the structure foundation, including porches, decks, and any other appurtenances. If you are unsure as to the exact location of the septic system, please have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed. 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 ONo Applicant/Legal Reps. Signature: *Date:. *Issued By: 2244 - Daywalt, Andrew *Date of Issue:_ 0 4 1 a a a 0 1 3 Authorized State Agent-OAA6 - &4&AW **Site Ian/Drawing attached.** TotalTime:(HH:MM) 0 1 Hours 3 0 Minutes O Hand Drawing OlmportDrawing . 3 Davie County Health Department 9 N06j� Environmental Health Section'ell P.O. Box 848 . 210 Hospit d Street Q �'t Courier # : 09-40-06 ; , , , 1911 Mocksville, NC 270 /4 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CE l+I Fax: (336) - 753-1680 (Check One) Replacement. Remodeling Recon 'on Name: Mailing Address: Detailed Directions To Site: Phone Number 1hi4ieq (Home) f (Work) L Email Address < (k%ti Please Fill In The Following Information Abut The EXISTING Facility: Name System Installed Under: Type Of Facility: �/ r Date System Installed (Month/Date/Year): / / 0 -5 Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? U1 Ye3 No If Yes, For How Long? ) Any Known Problems? Yes No If Yes, Explain:��{�/.��(,1,)I" Please Fill In The Following Information About The NEW Facility: gl/ Type Of Facility: Slialt fIyltse'- Number Of Bedrooms: Number of People Pool Size: By: �-Requested (Si Garage Size: Approved Disapproved Environmental Health Specialist. Other: pate Requested: For Environmental Health Office Use Only 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(-SAsV Check Money Order # Amount:$ - Paid By: Received By:_ Account #:Q n � Invoice #: i /� IIlu FA PROPERTY OF TERRY GRAY SMITH 3YCe 3RD—�qYk BEGINNING at a point, an iron stake in the West edge of right of way of SR 1452, Peggy R. Dunn's Southwest corner, as appears from a deed recorded in Book 62, at page 524, Davie County Registry, being the Northeast corner of the within described tract, runs thence with the said . road the following calls: South 35 Begs. 19 min. West 100 feet to a point, an iron, South 26 degs. 40 min. West 170. 28 feet to a point, an iron, South, -47 degs. 52 min. West 100 feet to a point, an iron, Richard A. Sheets Northeast corner in said right of way; thence with said Sheets line the follow in$ calls: North 80 dego. 12 min. West 257. 1.6 feet to a point, an old iron, and South 8 degs. 12 min, West 291.15—feet to a point, a stone In Richard A. Sheets' corner; thence North 84 degs. 43 min. West 202 46 feet to a point, a stone, said Sheets corner; thence South 3 degs. 22 min, West 163. a8 feet to a point, a granite. monument, common corner of.Luther Ellis and Ernest McKnight; thence with Ernest McKnight line North 30 dogs. 21 min. West 728.03 feet to a point, an iron stake in said McKnight line, George F. Wilson' —corner; thence with Wilsons line the following calls:' South 81 degs, .11 min. East 157. 5 feet to point, an iron and North 18 degs. 17 m' in. East 263.61 feet to a point, an iron in said Nilson line, Gray D. Boggs corner; thence South 87 degs. 57 min. East 365.92 fee to a point, an iron, common corner of Willie M. Cope and .Gray )3-g ggs, thence with the said Cope line South 87 dege. 36 min. East 356.95 feet to a point, an iron, said Cope xorner; Peggy R. Dunn's line; thence with the said -Dunn's. line South 6 degs. 44 min. West 86. 68 feet to ? a,point, -an Imn, and South 76 dege. East 90. 66 feet to the BEGINNING, containing 10. 770 less as taken f m a lat an vey preparedby C. Quote Re tat ed Surve or dated June 4 1973. SAVE & EXCEPT a perpetual easement for purposes of ingress, egress and regress 12feet wide ektending along the North boundary of said tract ,fro m its point of beginning to a� point which lays North 87 degs. 50 min. West 12 feet of the common corner of Gray D. Boggs and Willie M. Cope in said line, running parallel to the property lines of Gray D. Boggs, Willie M. Cope and Peggy, R. Dunn, Appraisal Card DAVIE COUNTY. NC Page 1 of 1 4/8/2013 11:35:48 AM DWELL LEE ROY TRUST HOWELL JUDY A & ANN TRUSTEES Return/Appeal Notes: B7-000-00.004 ATALIES WY UNIQ ID 983 ' 2520352 ID NO: 5863232822 COUNTY TAX (100), FIRE TAX (100) CARD NO. 1 of 1 eval Year: 2013 Tax Year: 2013 9.11 AC YADKIN VALLEY RD 9.040 AC SRC= Inspection kppraised by 01 on 04114/2008 03001 SPARKS RD TW -03 C- EX- AT- LAST ACTION 20110712 ONSTRURION DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE . OTAL POINT VALUE Eff. BASE UA BUILDING USE MOD Area L RATE IRCNIEYBIAYBI CREDENCE TO 1 1 1 1 1 % GOOD DEPR. BUILDING VALUE - CARD ADJUSTMENTS 971 00 1 1 TOTALADJUSTMENT TYPE: Vacant DEPR. OB/XF VALUE - CARD ACTOR MARKET LAND VALUE - CARD 114,46 TOTAL QUALITY INDEX STORIES: TOTAL MARKET VALUE - CARD 114,46( TOTAL APPRAISED VALUE - CARD 114,46 TOTAL APPRAISED VALUE - PARCEL 114,46( TOTAL PRESENT USE VALUE - PARCEL 2,44 TOTAL VALUE DEFERRED - PARCEL 112,02 TOTAL TAXABLE VALUE - PARCEL 2,44( PRIOR UILDING VALUE BXF VALUE AND VALUE 114,46 RESENT USE VALUE 1,45 DEFERRED VALUE 113,01 TOTAL VALUE 114,460 PERMIT CODE I DATE I NOTE I NUMBER AMOUNT ROUT: WTRSHD: SALES DATA FF. RECORD ATE DEED INDICATE SALES BOOK IPAGE 1MOjYR I TYPE / / PRICE 002E 145 13 OOA WL I E I 1 HEATED AREA NOTES SE IS NOT LIVABLE -NV SE IS OVERGROWN CANT .66 AC TO WILLIE SMITH ET TO IT. ONLY SEE ROOF SUBAREA UNIT ORIG %SIZE ANN DEP % OB/XF DEPR GS RPL OD UA DESCRIPTIO LTH NIT PRICE COND LDG. L/ FAR Y EY RATE V COND VALUE TYPE AREA CS OTAL OB XF VALUE IREPLACE UBAREA OTALS UILDING DIMENSIONS AND INFORMATION IGHEST THER ADJUSTMENTS TOTAL ND BEST USE LOCAL FRON DEPTH / LND COND NO NOTES ROAD LAND UNIT LAND LINT TOTAL ADJUSTED LAND LAND SE CODE ZONING TAGE DEPT SIZE MOD FAR RF AC LC TO OT TYPE PRICE UNITS TYP ADJST UNIT PRICE VALUE NOTES URAL AC 0120 1 150 0 1.1660 4 0.9200 03 +20 +00-15-10 PW 11,800.00 9.040 AC 1.073 12,661.4 11445 OTAL MARKET LAND DATA 9.04 114,46 RSTII 6210 0 0 1.0000 5 1.0000 270.0 9.040AC 1.00 270.0 2441 OTAL PRESENT USE DATA 9.04 2,741 � 1An �1D ul http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=B700000004 4/8/2013 Iron Stake In Iron Stake in I eil Iron Stake in common comer of 365.92 Willie M. Co e & Gray D. Boggs Iron Stake in 128.9 Co e corner 356.95 '^ b c 12.00 6° r g N Easement 30.00 ^ N s ry 33.00 22.00 Begin Survey Proposed Location of Iron Stake in West edge of 660 sq n Dwelling right of way of SR 1452 8 with full basement Pegg y R. Dunn's SW comer Stake \Von Richard A. Sheets NE comer South 39deg 19min West 100ft -Iron South 26deg 40 min West 170.28ft ton v South 17deg 52min West 100ft-Iron N North 80deg 12min West 257.18ft - ton South 8deg 12min West 291.45ft - Iron North 84deg 43min West 202.46ft - Stone 811 South 3deg 22min West 163.86ft - Granite Monument North 30deg 21 min West 728.0311- ton $ouch 81 deg 31 min East 157.5ft - ton North 18deg 17min East 263.610 - ton South ot87g36minEst 35695t-nNorth de.fVo 00° South 76deg 90.168ft etost nd.68ft-ton 0.770 Acres after adjustment 202.46 moved accre s19.04 foPPerox:l W E Includes perpetual easement for ingress, egress, 12ft Northern boundary and regress wide along beginning point to Gray D. Boggs and ^ T i r Willie C 21' Also Included are sections removed in NW corner e In RirhnrelA. t for Willie Smith and Linda Smith (not verified by survey) 3°22' Granit monument common comer of Luther Ellis & Ernest McN1 ht - - - Property -" Way Top Asse`mbty - Water and APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)753-6780/ Fax (336)753-1680 Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) q Both Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. APPT.TC;ANT TNFORMATTON Name ' i N,rrm Contact Person M (CKE' A/A '��12 Address Lh R Home. Phonerc� 3sc —�9 / —q% City/State/ZIP VU C, A-7 O (Z. Business Phone Email X_ Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 1N FUKMA l TUN 'rllate House/Facility Corners NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) --3-2 C (Permit is valid for 60 months with site plan, no expiration with complete plat.) 01 —2 Y S� Owner's Name ' _'Z�rLt G -Phone Nurp3?6 7-19 2-1 4- Owner's Address 1 -o M!23 CL, 2 City/State/Zip C. . Property Address �" t P _ �`'..� y� � uaA City (3�t)r�h.yC � 1'��... � i vo C Lot Size Tax PIN# Subdivision Name(if applicable) Section/Lot# Directions To Site: If the answer to any of the following questions is "Yes",supportin documentation must be attached: 7Yes Are there any existing wastewater systems on the site? No . Does the site contain jurisdictional wetlands? Yes +/No Are there any easements or right-of-ways on the site? 7Yes _No . Is the site subject to approval by another public agency? Yes ,�LNo Will wastewater other than domestic sewage be generated? _ Yes ✓No TF RFS1DFNCF FTT,T, OI TT THF, BOX BELOW # People I— # Bedrooms I- # Bathrooms _� Garden Tub/Whirlpool ❑Yes '14o Basement: Yes ❑No Basement Plumbing: ❑Yes ';�.No TF .NON-RFS1DF,NCF., FILL, OUT THF, BOX BFIOW 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 [I Alternative El Other Water Supply Type: ❑ County/City Water ❑ New Well Axisting 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 withapplicable 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 staking the house/facility location, proposed well location and the location of any other amenities. Property owner's or owner's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Account # Revised 11/06 Invoice # C(