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482 Will Boone Rd (2)Davie County, NC Tax Parcel Report Tuesday, October 11, 2016 WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number: K50000006901 Township: NCPIN Number: 5747900828 Municipality: Jerusalem Account Number: 8304465 Census Tract: 37059-807 Listed Owner 1: KOKOSZKA LORY Voting Precinct: JERUSALEM Mailing Address 1: 482 WILL BOONE ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overlay: Zip Code: 27028 Voluntary Ag. District: Legal Description: 1.000 AC WILL BOONE RD Fire Response District: Assessed Acreage: 0.95 Elementary School Zone: Deed Date: 12/2014 Middle School Zone: Deed Book / Page: 009750654 Soil Types: Plat Book: Flood Zone: Plat Page: Watershed Overlay: Building Value: Land Value: Total Assessed Value: 9"�'�' Davie County, `'°vN�c; NC 128850.00 Outbuilding 8� Extra Freatures Value: 14540.00 Total Market Value: 143870.00 JERUSALEM CORNATZER WILLIAM ELLIS CeB2 DAVIE COUNTY 480.00 143870.00 No , � Perinittee's ---'�" r DAVIE COUNTY HEALTH DEPARTMENT �� ' �" ' '" ��'`�`F � r�i t';:}+` t`r I Environmental Health Section PROPERTY INFORMATION � i�ame: '� '�v _ ,� � � .. _ �..... G - y, �";,'; , , , j�i P.O. Box 848 �(/ Directions to prorerty: ./ „0 = f!1}' l'�'L�r ut / h1ocksville, NC 27028 Subdivision Name: f ; , . r' ,� � f: Phone #: 336-751-8760 � � l � r ;',�• �,/+=; �' ��' f ( Section: Lo[: AUTHORIZATION NO AUTHORIZATION FOR WASTEWATER Tax Office PIN:#_ SYSTEM CONSTRUCTION Road N Zip: **NOT'E** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environment�l Health Section prior to issuance of any Building Permits. 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 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) , f}, ,�t _***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION 1 "�� _ � . `"'�L:, ,.�' ,' , ,r ,�' -;-� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL'NEALTH SPECIALIST DATE ISSUED ,� RESIDENTIAL SPECIFICATION: BUILDING TYPE �# BEllROOMS � # BATHS �# OCCUPANTS I GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE LOT SIZE TYPE WATER SUPPLY SYSTEM SPECIFICATIONS: TANK SIZE _ REQUIRED SITE MODIFICATIONS/CONDITIONS: # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or No DESIGN WASTEWATER FLOW (GPD) �-� NEW SITE REPAIR SITE �` 4L. PUMP TANK GAL. TRENCH WIDTH C�G � ROCK DEPTH ��/ LINEAR FT. �� f�!, .�i'�:J � } � v� "'*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. I OPERATION PERMIT SYSTEM INSTALLED BY: a�; a� AUTHORIZATION NOL�� OPERATION PERMIT BY: DATE: /•`�/S�G� � •"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE �� WITH pRTICLE 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. nctin o2roz �Re��ua� . ', r 1 �� ,��i,�� + � � �,PR 2 � �003 EP7ti'IRO `riET t,;.t�1F�� W. Name: � C: COUNTY HEALTH DEPARTMENT Environmental Health Section PO Box 848/210 Hospital Street Mocksville, NC 27028 Phone: (336)751-8760 TEWATER CERTIFICATION FOR DWELLING ❑ REMODELING ❑ RECONNECTION ❑ Number: 1 G% �' ` c/ / 0 5� (Home) Mailing Address � Lf�i� w i l i 1� c�c►ne �� , (Work) /7%o c.iss �," ll� . 1� c. �'�02� Detailed Directions To Site: 6 �/ S �o i e. "F�- �� Lc.� mo n �"1 0 ��( �' o v',� q�� 1n� � �� C3oc.>,� � /�� Ct,b n c,�"f �> -� ir� ►� %�e, %c'�-� S%r� .� r o w r� �' � Yl. f�¢. w i�� o�'� /'Q T'(" Property Address: ��Z- W i�� •Qd e n.Q ��c+a.�� Please Fill In The Following Information About The Existing Dwelling: ' � �f a,�� Nazne System Installed Under: o� A t R, /'��- ��a.�c� Type Of Dwelling:•� ,�r+c i�, . m ob �%4 Date System Installed(Month/Day/Year): %��`7 Number Of Bedrooms: -� Number Of People: � Is The Dwelling Currently Vacant? Yes ❑ No f�f If Yes, For How Long? Any Known Problems? Yes ❑ No � If Yes, Explain: Please Fill In The Following Information About The New Dwelling: Type Of Dwelling: �. o�4�`— Number Of Bedrooms: � Number Of People: / Requested By: �� Date Requested: //�' T/� �GG /1 v ��° Approved �Disa�prov�ed Environmental Health For Environmental Health Office Use Only L 7 !� � �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. vo Payment: Cash ❑ Check ❑ Money Order ❑# Amount: $ � Date: Paid By: Received By: Account #: Z"� % b Invoice #: �� `� 0 0 ��l)-��. �.,� �. ' APPI.ICATION FOR SITE EVALUATION IMPROVEMENT P D� �`` , � / O �� ` � Davie County Health Department � e Environmenta/Hea/th Section �CT � P.O. Box 848/210 Hospital Str t � 20�� Mocksville, NC 27028 ` (336) 751-8760 ��R�NMEN�� , �AVjFCO HEACTy �. ***II�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE D INFORMATION IS PROVIDED. Refer to the INFORMATION BLTLI,ETIN for instructions. 1. 2 Name to be Billed �i O S�,.c� �.. %la !'M ctti Mailing Address �Q, ��X �(, / f ' City/State/ZIP �S+ kC.� . �/Q.J %�.e . Z � 0 � � Name on Permit/ATC if Different than Above_ sq m�- Mailing Address S 3. Application For: �Site Evaluation Contact Person �0'� _ HomQ Phone 9 qg� �% %% 7 Business Phone S �s'�'�"— � � t�- ! l � i � r� 6 h��^` City/State/Zip -Improvement Pe�ii.t/ATC ❑ Both 4. system to service: � House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People ) q Bedrooms _�_ # Bathrooms � L�? Dishxasher O Garbage Disposal [�l Washing Machine ❑ Basement/Plumbing I7 Basement/No Plumbing 6. If Business/Indust=y/Other: Specify type # People A Sinks # Commodes # Showers # Urinals � Water Coolers IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: � County/City ❑ Well C1 Community s. Do you anticipate additions or expansions of the facility this system is intcnded to scrve? If ycs, what typc? ❑ Ycs f�Q No ***IMPORTANT*** CLIENTS MUSTCOMPLBTETHE REQUIRED PROP�RTY INI'ORMATION REQUGSTCD .. BELOW. Eithcr a PLAT or SITE PLAN MUST BESUBMI7TED by thc clicnt �vith TH1S AI'PLICATION. Property Dimensions: � �'e ^''-� Tax Officc PIN: #.S`%�l7� 9a ^ 0$� `6 � Property Address: Road Namc � W; )ibaone. � �� c�tyiz�p.�'lo�kS�,; J l�, �7 �� If in a Subdivision provide information, as follows: � Name: ? Section: Block: Lot: WRITG UI[iL:CTIONS (from Mocksvillc) to PROI'l;R'1'1': O��-S �'O �Z'�� 6h�IY�en /1G�, Y' i �� '�' �li i �!/� p o R c.. �O a, c1 . �%o��- 2 �+'1� �e,s -fo ,�!^aw� s i na�¢ yU i ci �+ �Ylo �� t %,om e � �� e."F'i- . /�e. /G.I.c� ,s �C,�t.i n� mo A� �e i20h'�a_ Datc Property Fla�ged: � ��a � o z Th' ' t rt'f th t th ' f t' r idcd 's c rcct t thc best of m lcnowlcd c 1 undcrstand that an crmit(s) �s �s o cc i y a c�n orma �on p ov i or o y g. y p issucd hcrcafter are subjcct to suspension or rcvocation, if tl�c sitc plans or intendcd usc changc, or if thc informalion submitted in this application is falsified or changed. I, nlso, rurderstau�! Niat 1 am respaisiGle for a// c/rnrges incrrrred fran tlris application. I, hereby, give consent to the Authoriud Representative of the Da�v'f Count I-ie. li Depart�ucnt to cnter upon abovc describcd property locatcd in Davie County and oivned by _/_.f _ _ to conduct all tcsting proccdures as nccessary to determine thc sitc suitability � DATE �� •� 1,, Zo o�, SIGNATUI2� ��..,Q �. �s2� � THIS AREA MAY BE USED FOR DRAWING YOUR SIT� PLAN (Include all of tf�c following: �xisting and proposcd property lines and dimensions, structures, setbacks, und septic locations). V J � � y.J � [ � �- ,^J Reviscd DCHD (07/99) Sitc Rcvisit Cl�argc Datc(s): Clicnt Notitication Datc: �HS: Account No. � ` •/ ,� Invoicc No. vZ�-- -�� .� � .----- . , 62 I �-� ; `� 5861 Mo� �� i � �� a IN vM f� � � 6 �� I � (1.44A) i p, O � � � �� 4��2 I! 2�� 2 6689 �48 � .1 '� �o ,��o I � � � � 10.86A � �� 15151 ! `� I �'� 1.29A �� I �22 . / 4446 .__ _- --- , _ _ i _. � � h / I 1$\_,v �j/ s�-_ 6333 �� I M C6 I �,�° (1.52A) � � � 3226 4285 M I �o`'� v� � �,� � (6.54A) � ; ''6• i ,� I �45 8109 i � 2S 4y9 (11 s� , � �, I /<`e��NFRo �� O 3oos 6036 (1.32A) o� so24 �So 2'8 � ; N ' K50000006901 �� y_�t �' N °� / � � ��S (10.51A) � a � 5936 N � �� s�*�' 8908 j /i? i i I � �� I 9 � �� / �� I� ( _�. r'O�� i � �Q828 �,� � � r�9J i 004270442 I' 9S � � � (4.26A) �' '� � °/ �� 2786 � � (1.23A) �� 1� 4 �„ 4659 � �� `r � � � I. �� cv '� 3'15 � �� 23� s'Q,�� I �, � � � �\ �o� � �� J ' �� `'09 � , ' �� . 4325 \ � ' � � �� '��. 2335 � (3.88A) � � � 5325 / � � �o� oo� � � �'�� I (9.10A) � �°` = � 8244 � �O �`�� 55`�� _ � � DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section , � . • Soil/Site Evaluation APPLICANT INFORMATION Account #: 990002490 Billed To: Joseph Norman Reference Name: Proposed Facility: Residence PROPERTY INFORMATION Tax PIN/EH #: 5747-90-0828 Subdivision Info: Location/Address: 474 Will Boone Road-27028 Property Size: see map Date Evaluated: /�"/ �'0 � Water Supply: On-Site Well Community Evaluation By: Auger Boring Pit Public V Cut HORIZON I DEPTH Texture group Consistence Swcture Mineralogy HORIZON II DEPTH Texture group Consistence Structure Mineralogy HORIZON III DEPTH Texture group Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 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- 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 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-terrn acceptance rate - gaUday/ft2 DCHD OS/99 (Revised) ■ ■ ■ ■ ■ �� ■ ��0�� ■��■��N��■ ■��■�■��■�■ ■��■��■■�■ ■ ■ ■ ■ ■�■ ■�■ ■��■ ■��■ ■��■ ■��■■ ■��■ ■��■ ■��■ ■��■ ■�■�■■■ ■��■ ■��■ ■��■ ■��■�■ ■��■ ■��■■■ ■��■�■ ■��■��■��■�\■�■��■�■ ■/��/�■ ■��■\■��■��■��■ ■��■��iir��■��/�■■ ■�i��/��i%i%��■ �� ■��/��■ �� ■��■ ■��■��■��■■ ■��■��■��■��■��■��■■ ■��l��■ ■�■��■�■■�■��■ ■��■��■��■■�■��■��■ ■��■��■■ ■�■��■��■��■�■��■ ■��■��■��■ ■��■��■��■■�■��■��■��■��■■ ■�■��■�■��■��■��■��■■��■��\�■ ■�■��■��■��■��■��■ ■��■��■��■��■��■�■■��■��■��■\■■��■ ■��■■�■��■��■��■��■��■�■��■��■ ■�■��■■�■��■ ■��■■��■��■��■��■■ ■■��■��■��■��■ ■��■��■��■��■��■ ■■��■��■■�■�■■�■■��l�■�■��■��■��■ ■�■��/��■ ■�■��■��■��■�■■�■��■�■■■��■��■�■■��■ ■�■ ■■ � , � � P^�� C6�L1� ��'T� ��i��.'�� b �.� � , ��.�.�_�.. _,� � _. _ _��... �� . . _ . .. . . _ ___ :�� .__.�._ _�__�.. _. ENVIRONMENTAL HEALTH SECTION P. 0. Box 848/210 Hospital Street . Courier #09-40-06 Mocksville, NC 27028 n . ,. �. . , . __. . . .. Phone #: (336)751-8760� � . November 4, 2002 Joseph Norman P.O. Box 1611 Mocksville, NC 27028 Re: Site Evaluation/ Will Boone Road Tax Office Pin : # 5747-90-0828 Dear Client(s): As requested, a representative from this office visited the aforementioned site on November 1, 2002. Based upon the information provided on the Application for Site Evaluation and after an evaluation was completed on the site, the site was found to be provisionally suitable for the installation of an on-site sewage system. Before an Improvement Permit/Authorization to Construct can be issued the appropriate application must be filled out and the house/mobile home location staked off. If you have any questions, please feel free to contact this office. Sincerely, /�D� � �a��J. Robert B. Hall, Jr., R.S. Environmental Health Specialist I: . �