250 Potts Rd Davie County,NC - ' . Tax Parcel Report (��,3 Wednesday, October 5, 2016
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WARNING: THIS IS NOT A SURVEY
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Parcel Information
Parcel Number. F80000012203 Township: Shady Grove
NCPIN Number. 5880157312 Municipality:
Account Number: 15994250 Census Tract: 37059-803
Listed Owner 1: CLINE RICHARD EUGENE ETAL Voting Precinct: ' EAST SHADY GROVE
Mailing Address 1: 250 POTTS ROAD Planning Jurisdiction: Davie County
City: ADVANCE Zoning Class: DAVIE COUNTY R-A
State: NC 2oning Overlay:
Zip Code: 27006-0000 Voluntary Ag.District: No
Legal Description: 1.086 AC OFF POTTS RD Fire Response District: ADVANCE
Assessed Acreage: 1.06 Elementary School Zone: SHADY GROVE
Deed Date: 6/1998 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 002030241 Soil Types: WeC,PcB2,RnD
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 0.00 Outbuilding 8�Extra 0.00
Freatures Vatue:
Land Value: 15360.00 Total Market Value: 15360.00
Total Assessed Value: 15360.00
q�,�E, All data b provtded as is wMhout warta�Ry or guaraMee of any Idnd either expressed or Implied including but not Iimlted to the
Davie County� Implled warrarAlea of inerchaMabllity orfitneas fw a particular usa All users oT Davie Cou�s GIS webaRe shall hold harmless the
Nr County oT Davie,Nath Grolina,ib ageMs,eonwltaMs,contractors or employees ttom any and ap daims or wuses of actlon due to
�'p��.�� t� or aAsing out of the use or inability to uu the GIS data provided by thia websita
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AUTHORIZATIONNO O 6 3�� DAVIE COUNTY HEALTH DEPARTMENT
�;,,',.�'�- � Environmental Health Section L�� PROPERTY INFORMATION
"Permrttee's� ; • P.O.Box 848. �
Name:`�`_�� ArA� ,�n L- Mocksville,NC 27028 .� Subdivision Name:
,Q Phone#:704-634-8760 C�' ���-'�-�
, Directions to property: .��S�t" G�(� Section: .beC"
AUTHORIZATION FOR r�►c!
� ' WASTEWATER Tax Office PIN:#�8 0 �-�_ ���
SYSTEM CONSTRUCTION.
Road Name: /�U r/S C� , Zip; 05 7d��'
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Counry 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 Pernuts.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems;Section.1900 Sewage Treatment and Disposal Systems)
' ,,,.,`) ..;-s / . ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
.
! J,,��',t�. �'"�f�l--C��!'�7 -'. _C',� IS VALID FOR A PERIOD OF FIVE YEARS..
- ENVIRONMENTAL HEALTH SPECIALIST '. bATE ISSUED "
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fidt.._�..i-"�.�,• 4 i�.. �c� � ritiv' S ,-,`•^�s; ,� ti �sc%xti � .zt.�w� - .,,. , ��4
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y, � ""`~�-- ���A'� - ,�..,,.�^� DAVIE COUNTY HEALTHYDEP�R1i��ENT} ' I ��,�
�,-�• " � IMPROVEMENT AND OPERATION PERMI�'5:.� PROPERTY INFORMATION �
,�'Permittee'���.- / � / y:��,��;�
- N me.� . 'i C/IF,�'� ��✓�h � '
. �`'�Subdivision Name:
_ �,, , �J, ,,,,•j., �
Diiections fo property:_ � .'" .i%'' ��( '�'` � Section: .I�t�
IMPROVEMENT .
PERNIIT ' Tax Office PIN:#��u`��-�- '���
' Road Name: �C.��...,:. �C..� , Zip: "�i /vd �
**NOTE**This Improvement Pernut DOFS NOT authorize the construc6on or installatian of a septic tank system or any wastewater system.An
ALTTHORIZATION FOR WASTEWATER SYSTEM CONSTRUGTION must be obtained from this Department prior to the
construcdon/'uistallation 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)
r' �' ,r r.- ,,,� ***NOTICE***THLS PERMIT IS SUBJECT TO REVOCATION IF SITE
;"1f�zr�4ti � ;%` r ��'��-r" ,✓`'r�% ;i-�»/",` ••J,1 PLANS OR Tf�INTENDED USE CHANGE.YOUR WASTEWATER
�ENVIRONMENTAI.HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE
INSTALLING THE SYSTEM.
_
RESIDENTIAL SPECIFICAT'ION:BUILDING TYPE�� #BEDROOMS�#BATHS � #OCCUPANTS .� GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLF/SHIFf #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE �/I C TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD) 1/� NEW SITE� REPAIR SITE
SYSTEM SPECIFICATTONS: TANK SIZE'�G�7p GAL. PUMP TANK GAL. TRENCH WIDTH �� ROCK DEPTH �% ' LINEAR FT. � �'�'�'
OTHER
. ,
REQUIRED SITE MODIFICATIONS/CONDITIONS:
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IMPROVEMENT PERMIT LAYOUT
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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(704)634-8760.
OPERATION PERMIT .
SYSTEM INSTALLED BY:
IfJOL�/'lG'� ,
�
AUTHORIZATION NO._��OPERATION PERMIT BY: .l U DATE: �
**Tf�ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TE�SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WTfH ARTICLE 11 OF G.S.CHAP'TER 130A,SECI'ION.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) ,
,
, eAPPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC ----- �
,, � ° Davie County Health Department � �(2 a(\/]�
' Environmental Health Section D LS v
P.O.Box 848
Mocksville,NC 27028 � � � ���Qg"�"
(704)634-8760 I���
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****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS D UNLESS
ALL THE REQUIRED INFORMATION IS PRO ED. �'� �
• 1. Name to be Billed �C�Q��/ �/� ''►� Contact Person_�/�e7���-1 ���'
Mailing Address „�� � � �� �U� Home Phone ��d "���d
City/State/Zip ./'k?'UE�h�'� �� r����+° Business Phone t 19�' �G3`J
�� �� � �� � ��?��- l�b �
2. Name on PermidATC if Different than Above �, +L C�v-�+ • rt� �
Mailing Address /"�b' �� ��� City/State/Zip�f�G�'��h C' � /�- ��
3. Application For: -rd`�Site Evaluation � ❑ Improvement Permit&ATC �Both
4. System to Serve: ❑ House �Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People �_ # Bedrooms c�' # Bathrooms �
❑ Dishwasher ❑ Garbage Disposal �Lt'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 �ell ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ��10
. If yes,what type?
PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: � Q��Q � WRITE DIRECTIONS(from
� Mocksville)TO PROPERTY:
Tax Off'ice PIN: # s� � � - �_ - 1 '`� ' 1.�
� '' f �, .� d �'� .��Xi� -
Property Address: Road Name / bT�/� � � -' ' ;
� � r� `� a �.
� city/Zip /! /J ��'� nI C' _ i v�'� /� �"/ /
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If in Subdivision provide information,as follows: 1 ,r � �^,,) ' �� �
' 1 �l•� LX..
Name: � �` c� ��d/�
l,� � /u
Section: �' �� /_ G�� /��'l. �...� ,�
�`�
This is to certify that the information provided is correct 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 charges incurred from this application.I,hereby,give consent to
the Authorized Repres ntative of the Davie County Health Department to enter upon above described property located in Davie County
1 �
and owned by �`" to conduct all testing procedures
. �-.
as necessary to determine the site suitability.
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DATE I " l � -' �� SIGNATURE /L� ) .�
Revised DCHD(06-96)
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60 120 180 ' 127 :LIBERTY CHURCH ROAD . '
, " M�CKSVILLE, N.C� 27028 .
I N FEET ; C 704) 492-56i 6 ;�
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,,' � DAVIE COUNTY HEALTH DEPARTMENT s�'��
. � Environmental Health Section sECTioN r e�'
SoiUSite Evaluation
APPLICANT'S NAME �lt�� DATE EVALUATED I-/.�'�7
PROPOSED FACILITY PROPERTY SIZE li1�
SUBDIVISION ROAD NAME ��'.��
Water Supply: On-Site Well ''� Community Public
Evaluation By: Auger Boring t� 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 �'1 �• �' ,� ��
Texture rou � L'
Consistence � ,. �
Structure $� Ji:- ���C S�
Mineralo ,' i ,'
HORIZON III DEPTH
Texture rou
Consistence
Structure i
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure "
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE .__. w
SITE CLASSIFICATION: EVALUATION BY:���
LONG-TERM ACCEPTANCE RATE: . / OTHER(S)PRESENT:
REMARKS:
LEGEND
Landscane 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-Subangulaz blocky PL-Platy PR-Prismatic
Mineralogv
1:1,2:1,Mixed
otes
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
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