194 Potts Rd ' ,
Davie County,NC . Tax Parcel Report b�33 Wednesday, October 5, 2016
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WARNING: THIS IS NOT A SURVEY
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i , Parcel Information y
Parcel Number: F80000012202 Township: Shady Grove
NCPIN Number: 5880158535 Municipality:
Account Number: 82513407 Census Tract: 37059-803
Listed Owner 1: LANE GLENDA C Voting Precinct: EAST SHADY GROVE
Mailing Address 1: 194 POTTS ROAD Planning Jurisdiction: Davie County
City: ADVANCE Zoning Class: DAVIE COUNN R-A
State: NC Zoning Overlay:
Zip Code: 27006-0000 Voluntary Ag.District: No
Legal Description: 1.505 AC POTTS RD Fire Response District: ADVANCE
Assessed Acreage: 1.46 Elementary Schooi Zone: SHADY GROVE
Deed Date: 12/1999 Middie School Zone: WILLIAM ELUS
Deed Book/Page: 003210096 Soil Types: WeC,Pc62,RnD
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 65640.00 Outbuilding&Extra 0.00
Freatures Value:
Land Value: 17830.00 Total Market Value: 83470.00
Totai Assessed Value: 83470.00
9�,�v r�, Afl daU Is pmvided as b wRhout warranqr or guanntee oT any Idnd elther expressed or Implied InWuding but not Itmited to the
Davie County� Implled wartaMles of inercha�rtability or fttnesa for a particular use.All uaers of Dade County'a GIS webstte ahall hold harmleas the
CourAy of DaHe,NoAh Carolina,its agmts,conwlhMs,co�Wadors or employees hom any�nd ae daims or causea of acdon due to
�O�ty� NC or artsing out of the use or inabtlky to use the GIS data provided by this websfta
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auTHORr�aTiorr ivo: O 6 3 3 DAVIE COUNTY HEALTH DEPARTMENT
'�-'�Y Environmental Health Section ^;�'��'. PROPERTY INFORNIATION
Permittee's /I� ' ' P.O.Box 848 �,�j���
� Name:�� � �? ` �CJP_ ' Mocksville,NC 27028 G� �} Subdivision Name:
,� . Phone#:704-634-8760 S���
Directions to property: f'�.,�`� ��.�� - Section: -�e#�'
AUTHORIZATION FOR Jd
WASTEWATER Tax Office PIN:#�4 d� _ I� -��'��
SYSTEM CONSTRUCTION
, ' Road Name: f 0/!S~ c�,.. Zip: 05��d 6
� **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pemuts.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits. .
• (In compliance with Article 11 of G.S.Chapter,i 30A,Wastewater Systems,Section,1900 Sewage Treatment and Disposal Systems) • `"
' ;1 ``; � �/�% ***NOTICE***TIIIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�,'�,cr.,�,�"+" �'� d�,.���. ,> r'`7;> /`�/.1"� '� ' IS VALID FOR A PERIOD OF FIVE YEARS.
� �
ENVIRONMENTAL�HEALTH SPECIALIST_: bATE ISSUED
�h��..i;i,rY�A�h�i��'F}a�{ J.w�..sti�ryjm✓1'#ti �7�� �.,,..�i�T.;u,A`d;'1N:,.�„tr.i�;�+^":�rro���.'�.:..k.�4�.�d..�-��r,� ... , , ya - rkr- .�.��.,.,- ,r ,,,..�L,f � r -.�:.;t.��.�AY .
t�4r�� �. .�^^ Y�1M�iJ.:.r..'4IY ���:fl r �4" Y�:`"�F.�� .
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��„'�� � w", DAVIE COUNTY HEALTH DEPAR�,M�1��T
��F�"=y.. . IMPROVEMENT AND OPERATION PERMIT$:,�' PROPERTY INFORMATION
. ,, _..,
Permit ee's- ' ' �,.;Y��,�"�
�` �r Name:� =�� �'r�.,�. ��?P � �� �...S bdivision Name: . .
,�. . . . _ .�i .�,;-- ;t�"
Directions to property: �"`�'"��f��' -'1 % Section: -L-op
Il1�PROVEMENT , � � � f�
PERMTI' Tax Office PIN:#..:s��L� _ �r _'�j'�'��r`�
Road Name.w�'��.'� '!'��L. Zlp; �:.1��`���'
**NOTE**This Improvement Pernut DOES NOT authorize the construction or installatian of a septic tank system or any wastewater system.An .
AU'THORIZATTON FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/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)
� ,,' � . ,. , �, ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
< , � �
,.�-,.�'�' •;Y'y' PLANS OR TFIE INTENDED USE CHANGE.YOUR WASTEWATER
` ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE
: INSTALLING Tf�SYSTEM. .
RESIDENTIAL SPECIFICATTON:BUILDING T'YPE�'�� #BEDROOMS C�'�#BATHS_�,#OCCUPANTS �� GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY T'YPE #PEOPLE #PEOPLF✓SHIFT #SEATS INDUSTRIAL WAST'E:Yes or No
LOT SIZE� TYPE WATER SUPPLY�DESIGN WASTEWATER FLOW(GPD) � l� NEW SITE � REPAIR SITE
, SYSTEM SPECIFICATIONS: TANK SIZE GGG GAL. PUMP TANK GAL. TRENCH WIDTH s - ��ROCK DEPTH� LINEAR FT. :��� � .
. OTEIER
REQUIRED SITE MODIFTCATIONS/CONDTITONS: - ,
.IMPROVEMENT PERMIT LAYOUT
�
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEAL;TH 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 INSTALLAT'ION.TELEPHONE#IS(704)634-8760.
OPERATION PERMIT ,�7���
SYSTEM INSTALLED BY:
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AUTHORIZATION NO.�OPERATION PERMIT BY: DATE: l ' "� _
**TI�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 WII,L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96(Revised) .
l . ' � ��
'"' ' � 1�APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT � � � � `� �
` Davie County Health Department �
Environmental Health Section � .-���j
P.O.Box 848 ��� �'`"''
Mocksville,NC 27028
(704)634-8760
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed ��d�U�Z LGI�-►-e Contact Person �/P��Q �a h e
Mailing Address /,�� �C�, ��9 Home Phone ���"'���//
City/State/Zip ��CY�Ct v/G'�' �� ��C�f9� Business Phone ll�`f ' S�'��
2. Name on PermidATC if Different than Above L."7/Pt�r O1G'_ G�Q�
+ Mailing Address /-,�� ����/ City/State/Zip�/�'��l�o� �L' Z"�l�a �
3. Application For: �� Site Evaluation ❑ Improvement Permit&ATC �d Both
4. System to Serve: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People Z # Bedrooms � # Bathrooms �
y
❑ Dishwasher ❑ Garbage Disposal f�Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage(gallons per day)
7. Type of water supply: ❑ County/City �Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes �YNo
If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
/
Property Dimensions: / /2 �l C �"CS � WRITE DIRECTIONS(from
� �/ �/ � Mocksville)TO PROPERTY:
Tax Office PIN: # � d - J �D (D
i `= 1� �'d� �
Property Address: Road Name 0 5 � L I
� � � !'/� T /7rN
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City/Zip l�G�c--e. a�bo� � '/� /, �� � o � �
� S�
If in Subdivision provide information,as follows: 1 • /
� pn �� �he o �
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Name: 1 �/�'0 a,/� � cz C C d
��� �� 1
Section: =��` � � r,��
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This is to certify that the information provided is correct to the best of my knowledge.I understand that any permit(s)issued hereafter
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 that I am responsible for all charges 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 by ,�/l P4?�e ( /•`�'�-� to conduct all testing procedures
as necessary to determine the site suitability.
DATE ��� r��P SIGNATURE � �"4-
Revised DCHD(06-96)
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99�- �/�d � - -�-��''��..
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-------.�`_,,; �S Ol' 1 S'07"E .13.54'
trom 1.5' iron tound .
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. new iron
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iron pivoed:.� . �, � R
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from O.b' iron found _ :,,•°
. 237.00 2"' iron found " :�;.
-�—:N 87'43'36' W 266.00 TOTAL. -' `—"'——"'--—--——
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D.B. 171 Pg. 121 � ':
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MOCKSV I LL.E, N.C, 27028 �
C 704) 492-5616 �' �
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_ � ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
SoiUSite Evaluation
APPLICANT'S NAME -�C�lt�t'% DATE EVALUATED l��97
PROPOSED FACILITY ��,J f7' PROPERTY SIZE � '`�
SUBDNISION ROAD NAME ���6 '
Water Supply: On-Site Well �l Community Public
Evaluation By: • Auger Boring ,�/ Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition -L ,L L
Slo e%
HORIZON I DEPTH
Texture rou
Consistence ,
Structure
Mineralo
HORIZON II DEPTH '� jp F t
Texture rou �
Consistence r- ,- �
Structure s'
Mineralo ;
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH '
Texture rou
Consistence
Structure
Mineralo � � -
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION S '
LONG-TERM ACCEPTANCE RATE ,
SITE CLASSIFICATION: -� EVALUATION BY: /`
LONG-TERM ACCEPTANCE RATE: ' 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-Slightly plastic P-Plastic VP-Very plastic
� tructure �
SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralo�v
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
� DCHD(01-90) . � �
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