167 Pebble Valley Way ,
Davie County,NC ' T�Parcel Report � a��" Wednesday, October 5, 2016
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WARNING: THIS IS NOT A SURVEY
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Parcel Number. F80000011106A Township; Shady Grove
NCPIN Number. 5880170645 Municipality:
Account Number. 100000251 Census Tract: 37059-803
Listed Owner 1: MYERS JAMES Voting Precinct: EAST SHADY GROVE
Mailing Address 1: 167 PEBBLE VALLEY WAY Planning Jurisdictlon: Davie County
City: ADVANCE Zoning Ciass: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27006-0000 Voluntary Ag.District: No
Legal Desc�iption: 5.213 AC OFF POTTS RD LIFE ESTATE Fire Response District: ADVANCE
Assessed Acreage: 5.27 Elementary School2one: SHADY GROVE
Deed Date: 1/2009 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 007790781 Soii Types: PaD,Pc62,PcC2
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Bullding Value: 0.00 Outbuilding 8�Extra 9000.00
Freatures Value:
Land Value: 47840.00 Total Market Value: 56840.00
Total Assessed Value: 56840.00
9�,v�� All data is provided as Is wlthout wartaMy or guanntee of any kind either expressM or impfled Ineluding but not Iimked to the
Davie County� Implled wartandes of inereha�Mablllty or fitness Tor a particulu use.All usera of Davte CourR�s GIS website shall hotd harmless the
CouMy of DaWe,North Grolina,lts�garts,conwitaMs,coMractors or anployees from a�ry and ap dalms or auses ot actlon due to
�p U N� N� or arisinq out of ttie use o►InabOriy to use tbe GIS data proNded Ay thts website.
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�AU�'HOP�?ZA�F ON N1D: ��r�i�ry� DAVIE COUNTY HEALTH DEPARTMENT
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��"_� ` ' � Environmental Health Section PROPERTY INFORMATION
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�"Permittee's P.O.Box 848:
Name: Mocksville;NC 27028 ,, Subdivision Name:
_ � �/ : Phone#:704-634-8760 ��.��,,J
;Directions to property` r � ` Section: Lo . {
= ,/ �,! AUTHORIZATION FOR
�.i>f�'`' �""'f�`I � "` +CJc'�!�'" ���� WASTEWATER Tax Office PIN:# y'� -��- ,�� .
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SYSTEM CONSTRUCTION .
��."�0 YJ� r Road Name: �� �i . Zip: �/l��i
**NOTE*,*This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts.This Forn�/Authorization Number should be presented to the Davie County Building Inspections :
� Office when applying for Building Permifs.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
�t ***NOTICE***TI�IIS AUTHORIZATTON FOR WASTEWATER CONSTRUCTION
, �" �- ' IS VALID FOR A PERIOD OF FIVE YEARS. ,
-ENrVIRONMENTAL HEALTH S CIALIST : .DATE ISSUED,
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-.� =�� � � � �"�"" DAVIE COUNTY HEALTH DEP RT ENT
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a j�"_�� "�,�,,,r.�.~ ,y� IMPROVEMENT AND OPERATION�ER�TS PROPERTY INFORMATION 1
`�Y��6I'llll�t�'S r^'� �' .._
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Name: ����'"�'�`��.+��'r"r�'�"� , _ Subdivision Name:
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��Duections to property: ,�"F-1i"f.i'� �''�"r��`� Section: Lot`"r���
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`;?f���'' �,�;f.1 % — �E�i_. �''y„��''"'� �PERMIT:. Tax Office PIN:#..,'��- /�`� - . �:�'�,..,..�'
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d � r re" r v r�'r�x„ ��ri
;;,,,.�.. .,-��!�1� �?� Road Name: .�� �Y; �. Zip: f �� ��
**NOTE**This Improvement Pernut DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.An
ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUGTION must be obtained fmm this Department prior to the
' conswction/installation of a system or the issuance of a building pernut.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) �
ff,�:-'�� r•� �, ,,,, ,° •' ,� . #**NOTTCE***TEIIS PERNIIT LS SUBJECT TO REVOCATION IF STI'E
,C.,%�'i`�a,t'�S.�;,Etsa�"����'�,j ...�"J��''li'� PLANS OR Tf�INTENDED USE CHANGE.YOUR WASTEWATER
F.NIVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE Tf�S PERMIT BEFORE .
INSTALLING Tf�SYSTEM.
,�y��� - _ . . .
: RESIDENI'IAL SPECIFTCAI'ION:BUILDING TYPE �•�r� #BEDROOMS � #BATHS�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No
COMI�ERCIAL SPEC�ICAT'ION: FACII,ITY TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE��� TYPE WATER SUPPLY ��� DESIGN WASTEWATER FLOW(GPD) �P� NEW SITE �REPAIR SITE
�,:
SYSTEM SPECIFICATIONS: TANK SIZE��� GAL. PUMP TANK GAL. TRENCH WIDTH��r / ROCK DEP'TH �� LINEAR FTS��
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OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: '
IMPROVEMENT PERMIT LAYOUT ,
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BET'WEEN 8:30-9:30 A.M.OR 1:00-1:30 P.M.ON T'HE DAY OF INSTALLATION.T'ELEPHONE#IS(704)634-8760.
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OPERATION PERMTT �� �
, � '�[ SYSTEM INSTALLED BY: � ^
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AUTHORIZATION NO. PERAITON PERMIT BY: / DATE: J /•�l L�
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD OS/96(Revised) _ '
. �,
. AP�PLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
_ �^ Davie County Health Department °
' ' Environmental Health Section
O � � � Q �
, `� P.O. Box 848 - � — 5 t�
,�j �� Mocksville NC 27028
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(704) 634-8760 ' �t�
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****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSE
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed /e n�a���(/'� Contact Person �Am�'-
Mailing Address %3'��}/1?,P��f► �1�i9� Home Phone �8-�0 7 f
City/State/Zip!-,It.11/A11G�'-� N�� • �7�L'� Business Phone
2. Name on PermidATC if Different than Above 5�e.
Mailing Address City/State/Zip
3. Application For: [ ]Site Evaluation [ ]Improvement Permit&ATC [✓]"Both
4. System to Serve: [ ]House [+�Mobile Home [ _]Business [ ]Industry [ ]Other
5. If Residence: #People .3 #Bedrooms 3 #Bathrooms � [�.J'Dishwasher[ ]Gazbage Disposal
[L]�Vashing Machine [ ]Basement/Plumbing [ ]Basement/No Plumbing
6. If Business/Other: Specify type #People #Sinks #Commodes
#Showers #Urinals #Water Coolers _
If Foodservice:#Seats Es6mated Water Usage(gallons per day)
7. Type of water supply: [ ]County/City [ti�'GVell [ ]Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes [�'No
If yes,what type?
°�` ' EZTHER tt PLttT OR SZTE PLAN
PROPERTY INFORMATION REQUIItED:***IMPORTANT**��4fi OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
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Property Dimensions: � �`/�e� �WRITE DIRECTIONS(from Mocksville)TO PROPER
Tax Office PIN: # r � - !� - �lo �S— ! �% D <D $O( dn.. 0 m ��7 .
Property Address: Road�ame �!3 ���s �c� • � ��� ,ADAI�o�x. � m��cs � t'p�s Qc� '[u,�nS
City/Zip �(/�I�JI�t�, N c 27 0v 6 � -�' - c� -cle-� e
If in Subdivision provide information,as follows: � -1 I� �� e -
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Name: � e n � � � �ee �
f � f _
Section: .Let�#: �f�� �
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This is to certify that the information provided is conect to the best of my knowledge. I understand that any permit(s) issued hereafter aze
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 that I am responsible for all chazges incurred from this application. I, hereby, give consent to the Authorized
Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned
b,�o��;i5 �2n� �1�f C�.�'S to conduct all testing procedures as necessary to determine the site suitability.
DATE .j-S-q� SIGNATURE ,� l����1�'J,c� e.�
Revised DCHD(06-96)
THIS AREA �ItIJ IIE USEb �OR bRAWZNC JOUR SZTE 1'L�N: .
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� - ' r , DAVIE COUNTY HEALTH DEPARTMENT
• � + � �� Environmental Health Section sECT1oN LOT
Soil/Site Evaluation
APPLICANT'S NAME P - DATE EVALUATED_i�//, ,S��
PROPOSED FACILITY iJ?/i� PROPERTY SIZE_5���
SUBDIVISION ROAD NAME_�_/�J(Z_�S
Water Supply: On-Site Well � Community Public
EvaluationBy: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L.
Slo e%
HORIZON I DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH �` ��'
Texture rou C G'
Consistence ,•
Structure � /( /.�iC'
Mineralo �
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH -
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: /l� EVALUATION BY: ���
�
LONG-TERM ACCEPTANCE TE: OTHER(S)PRESENT:
REMARKS:
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
Wet
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-5lightly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangulaz blocky PL-Platy PR-Prismatic
Mineraloav
1:1,2:1,Mixed
Notes
Horizon depth-In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
5aprolite-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
DCHD(01-90) � � � �
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