385 Williams Rd ` , ' , . ' • . DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P.O.B�a 848/210 Hospital Street
Mocksville,NC 27028
��QV� ��� i� �� (336)751-87G0
ci
Account #: 989900642 Tax PIN/EH#: 5768-27-2606
Billed To: Steve Russ Subdivision Inf ���
Reference Name: Beverly Russ Location/Addre : Wil 'ams Road-27006
Proposed Facility: Residence Property Size: 7.88 Acres
ATC Number: 2094
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MiJST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article I 1 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatu e: ` Date: �� �g9
�
ERTIFICATE OF COMPLETION
**NOTE** The issuance of this erti cate of Completion shall indicate the system described on Improvement/Operation Permit
has been installed in omp ianc with Article 11 of G.S.Chapter 130A,Section.1900"Sewage Treatment and
Disposal Systems,"b t sh 11 in O WAY be taken as a guarantee that the system will function satisfactorily for any
given period of time. � �- �
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Septic System Installed By: LJ�� � S
Environmental Health Specialist's Signature: Date: �
/
DCHD OS/99(Revised)
�y��,� ;,c/ CD�
. , DAVIE COUNTY HEALTH DEPARTMENT �� �J'2���� �
- , •. ; �, , ' • Environmental Health Section
P.O.Boa 848/210 Hospital Street
Mocksville,NC 27028
(336)7�1-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 9$9900642 Tax PIN/EH#: 576&27-2606
Billed To: Steve Russ � Subdivision Info:
Reference Name: Beverly Russ ��j� Location/Address: Williams Ro�d-27006
Proposed Facility: Residence '-ProperCy Size: 7,88 Acres
ATC Number: 2094 ����D���� '/�`3" "�
**NOTE** T'his Improvement/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this
Department prior to the construction/installation of a system or the issuance of a building permit(in compliance with
Articte I 1 of G.S.Chapter 130A,Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PFRMIT IS SUBJECT TO REVOCATION IF STTE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type #People � #Bedrooms S� #Baths�• �
Dishwasher: �4 Garbage Disposal: ❑ Washing Machine:� Basement w/Plumbing:� Basement/No Plumbing: 0
/
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size , �.SType Water Supply t1� esign Wastewater Flow(GPD)��� Site: New� Repair�
�� �C I
System Specifications: Tank Size�f.� GAL. Pump ank GAL. Trench Width� Rock Depth� Linear Ft.��
Other: D r .S/O
r� A , `
Required Site Modifications/Conditions: O /� r�liC�/,
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER WSER(S) IF G "BELOW
FTNISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m. or 1:00 p.m.to 1:30 p.m. on the day of installation. Telephone#is(336)751-87G0.****
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Environmental Health Specialist's Signature: s� � Date: �9�/ �
DCHD OS/99(Revised)
° ' . < A'?�LICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT�C AT � � � a��
� ' � ' Davle County Health Department D
Environmenta/Hea/tfi Se�ion ��';� 2 ,� ��
P.O. Boa 848/210 Hospital Street
. Mocksnille, NC 27028 �
(336)751-8760
.�
***,ZI�ORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLES3 ALL THL REQUIRED
INFORMATiON I3 PROVIDED. Refer to the INFORMATION BULLETIN for instructions. �
i. Nam� to b� Hiilad � )�U���_5 S contaat �rson �'�.�'[� J �
u a- � +c�
Mailinq Addross ��a. �9'C'U�� �� Homo 8hona Gl� 1 s�e
City/Stato/ZZP ��C I��cf`� '�, ����`�O.�iC Sueinass Phor►o ���—fl-� L (
2. Nama oa 8ormit/ATC if Difforant than Above � � TF ��
Mailinq Addr�as ��� City/Stato/Zip s/�
3. Appiication For: �Site Lnaluation C}'Zmpronement Permit/ATC 8'Both
a. sy.t� to so�i�.: O�House 0 Mobile Home ❑ Busiaess ❑ Industry ❑ Other
5. If Residence: �k People �f� Ik Bedrooms �_ i Bnthzooms av`a
�Diehwaahor ❑ Garbaqo Disposal Q�aahiaQ Machiaa Q"Sasamoat/Plumbinq ❑ Haswnt/No Plumbinq
6. Sf 8uainaas/industry/Othor: Spocify typo i Pooplo 1� Siaks
� Commodes !k Shoxera # Vriaals • ►Pator Coolers
IF FOODSERV=CE: # Seats Estimated �iater Usage (gallone �r aay>
�. Type of water suppiy: -l�County/City � Well ❑ Community
s. Do you anticipate additions or eapansions of the facility this system is intended to serve? 0 Yes @'No
If yes,wLat type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or STTE PLAN MUST BE Si1BMITTED 6y the client with THIS APPLICATION.
Property Dimensions: � �l��c-�'�-S WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Taa Office PIly1: # ��(���o�`�`C�� �' ��/� -�r, �c�s'n�,�,'� �c,
Property Address: Road Name �t I t+�l'11 S �� O �• �i� �� v�t�✓J
,
� c�ty�z�p � �'�' Go c�.ho�s+ ��n,lr. �C, o�bl�e�w�dec.,,�
If in a Subdiv�sion provide information,as follows: ����lpu.SC a�� C3v� C'�,5��jj;�(
Name: c�4 �� o�,� � � �� �
S��tion: Blcek: Lot: Date Property Flagged: lo����g�/
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
�Ssued hereafter are subject to saspension or revocation,if the site plans or�ntended use change,or if the information
submitted in this application is falsified or changed. I,also,und�rstand that I am responslble for all charges�ncurred jrom
this applicatlon. I,hereby,give consent to the Authorized Representative of the Davie Coanty Health Department
to enter upon above described property located in Davle County and owned by
to condact all testing procedares as necessary to determine the site suitabili
DATE f0 / � SIGNATURE �-
THIS AREA MAY BE USED FOR DRAWIIVG YOUR SITE PLAN(Include all of the following: Existing and proposed
property linea s�d dimensions, stractures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account Na ��
i'.:��;�i�ed TiCHD(07/99) Invoice No.
C�
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llAV1F.COUN'l'Y HEAL'I'H llEPAIt'TMENT
, �. .. �' � • . Environmental Health Section
� ' ' �� � ' Soil/Site Evaluation
APPLIrANT INFORMATION 4 PROPERTY INFORMATION
Account #: 989900642 Tax PIN/EH#: 5768-27-2606
Billed To: Steve Russ Subdivision Info:
Reference Name: Beverly Russ Location/Address: Williams Road-27006
Proposed Facility: Residence Property Size: 7.88 Acres Date Evaluated: �F�p"g�
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca osition
Slo % •
HORIZON I DEPTN — -� p..-
Texture rou L_
Consistence � S SS
SWcture r
Mineralogy � /; ' c:
"HORIZON II DEPTH —
Texture rou
Consistence �i "
Structure c� �
Mineralo /,' 4 �' !'
HORIZON IIl DEPTH f-
Texture rou
Consistence '�
Structure f-
Mineralo /- � `
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo "
p
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE S'
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE .
SITE CLASSIFICATION: � EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: m OTHER(S)PRESENT:
REMARKS: ��'z
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
ois
VFR-Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firnt
�
NS-Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
tru t�re
SC-Single grain M -Massive CR-Crumb GR-Granulaz ABK-Angular blocky �
SBK-Subangular blocky PL-Plary PR-Prismatic
Mineraloev
1:1,2:1,Mixed
otes
Iiorizon depth-In inches
Depth of fill -In inches
Restrictive horizon-Thickness and inches from land surfacc
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
UCHb (i2evised 05/99)
: , � -
--- (2236.29 total)
663.04
419.25
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> 2��8 71 N36°24'04"W� 249.90
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(382 20 total)
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3o CO '°°d'- 209 0
/ 35.46 - _ _._.__ - _
nail and cap in Lrd P/Knoil on (203.88 total) N85°1757"W + /
edge of pavement P K ^Qi1 ° ' r
N81 it 47"W'� \
3
NORTH of \ 138.03 w w P/K noilin
P'K na,1 7 5 1 road
C. D WILLIAfV1S NORTNo. ,n `307
D B 63 PG.2, `� o 0
N 00° 33�00"E — 6� N /V P/K nail n� of
278.70 o M SORA W. SMITH 30'/6 .' _ / road and branch
"' z C.B. 152 PG. 547 o ti 3
In N In m 'n
---- - --- --— - --- 349 40 i 145.00 Sq S9 Co M In N
- - - — -
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N 85° 45 17 W -- ° ___i . 3 23" w �
ZAREA = 0.975 ACRES 146.86 / ty
1 TAKEN FROM D.B. 152 PG. 547 I + �\ _\ 6
S
I
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640
'HEODORE A SHnAF ��
B. 122 PG 818 N 060 39' 03"E \
125.53 16.00 725. 37 + "' 163.63
(905.00 total)-■--- N 87°08'00 W � _' ---�.-`-.-_----._ ._ -
NATES P/K nail in 'iS, R, ICI 0
road
U
I ) ALL CORNERS MARKED WITH IRON STAKES EXCEPT WHERE NOTED. I AREA — I I .885 ACRES
C VIRGIL WYATT
2) + DENOTES AN UNMARKED POINT IN THE OF BRANCH OR ROAD. I
m
2 AREA = 1 . 170 ACRES { D.8. 134 PG.60
3 AREA = 9.056 ACRES I
4 AREA= 7.887 ACRES
5 AREA= 18 . 113 ACRES
r. D,+V.15 6 AREA= �' . 104 ACRES TOLERANCES REVISIONS SURVEY CLAUDE F. WILLIAMS , ESTATE
7 AREA= 2 .124 ACRES FOR
_ IE XCE•T AS MOF DI n,tU DATE BV
DECIMAL_ --�--
TDTAL AREA— 52. 339 ACRES 15 - 14 - 97 SPH DEED REFERENCE. D.B. I PG. AR
_ + - t -- - 09
TAX MAP REFERENCE I - 7 PARCEL I
7uwE 6C BY
FRACTIONAL s FULTON TWSP. DAVIE CO N.C.
s - —
DRAWH. N
SC I�E - 150' MATERIAL
t �_—._ _
tCNK'D DATE DRAWING NO
ANGULAR < — 6 3 /88
PP'D I 7 1 88 — 3
A
- 5 I SPH
SEISE-17x22
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1 Appraisal Card I Page 1 of 1 -
I � � . '��
�, . . , ,
DAVIE COUNTY NC �� 1 29 2013 4:12:41 PM
-� EDERAL NA7IONAL MOR7GAGE AS50 ReNrn/Appeal Notes: I7-000-00.001 'I
I 85 WILLIAMS RD I UNIQ ID 17106 � � i
2530420 D263-P17/D473•P16 ID N0:5768272606 . - I
COUNTY TAX(100),FIRE TAX(100) (ARD N0.1 of 1 = I
eval Year.2013 Tax Year.2013 7.88 AC WILLIAMS RD WILLIAMS EST 7.640 AC SRC=Inspection :
� raised b 19 on 09 04/2008 07001 SHADY GROVE TW-04 G EX-AT- IAST ACTION 20120820 T�,
CONSTRUCTION DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE
� oundation-3 EH. BASE � Standard 0.1300 �
ontinuous Footin 5.0 USE MO Area UA RATE RCN EYB AVB REDENGE TO MARKET ,
�� ub Floor System-4 Ol Ol 2 760 142 99.40 277045200 200 °o GOOD 87.0 DEPR.BUILDING VALUE-CARD 241 03
� I wood 8.0 '
� xterlor Walls-21 TYPE:Single Famity Residen[ial ' Single Family Residential DEPR.OB/XF VAWE-CARO �
� � MARKET LAND VALUE-CARD 80,72 .
' ace Britk 34.0 STORIES:1-1.0 Story OTAI MARKET VALUE-CARD 321,75
, oofing Structure-06 . ,
n ular Cathedrol 13.0 � �
' oofing Cover-10 ' OTAL AVVRAISED VA�UE-CARD 321,75 - �,
; ood Shin le/310 Shin le 6.0 , OTAL ACVRAISED VALUE-PARCEL 321,75 ,
', nterlor Wall ConstruRion-5 �
' wail/Sheetrock � 20A � OTAL PRESENT USE VAWE-VARCEL �- ��
�� n[erlor Floor Cover-12 � OTAI VALUE DEFERRED-PARCEL T �
� ardwood 10.0 OTAL TAXABLE VALUE-PARCEL 321,75 ,
' nterlor Floor Cover-14 � -
ar et 0.0 . PRIOR -
, ea[ing Fuel-04 � ; BUILDING VALUE 258,94 �
. Iectric 1.0 BXF VALUE .
� eating Type-10 , IAND VAWE 80,72 ,
� eat Pum 4.0 ' PRESENT USE VALUE �
DEFERRED VALUE
� ir Conditloning Type-03 � �
entral 4.0 OTAL VALUE 339 66
� drooms/Bathrooms/Half-Bathrooms +----2 3-----+-----2 6--.---+ '
�i /2/1 13.00 IBAS IWDD I '
I 1 I
i drooms I 1 1 CERMST �
� AS-3 FUS-0 LL-0 2 I $ CODE DATE NOTE NUMBER AMOUNT '
�� throoms 4 +--1 4--+ ' I
AS-2FU5-OLL-O I 7 � I i
� alf-Bathrooms +----Z1""+ 2"+"""29"'"---+ ROUT:WTRSHD: �
I +-1 �
I I I SALES DATA I
I AS-1 FUS-0 LL-0 I FF. INDICATE
OTAL pOINT VAWE I38.00 I F G D I I RECORD DATE DEED SALES I
I BUILDING AD7USTMENTS I I I I BOOK PAGE M R TYPE / / PRICE �
ize 3 Size 0.930 I
I = , 2 0308 759 7 199 WD Q V 5000
uali 4 ABAVG 1.200 2 Z '� g 0899 083 8 Ol TD P I
� ha e Desf n 5 FACTOR 5 1.100 3 3 ' I 0860 112 5 011 NW E I '
, OTAL ADJUSTMENT FACTOR 1.20 I I • I 0114 773 8 198 WD X V �
OTAL QUALITY INDEX 14 I I I
I I I '•
. }""21""} � }"'Zp"'"+ � �
+"""'37"---'--+ �'.
I F O P I HEATED AREA 2,365 - ,
� 8 8 -
I +-------37=��-------+ NOTES ` I
I � -
LAUDE WILLIAMS EST -
i SUBAREA UNIT ORIG% SIZE ANN DEV % OB/XF DEVR ` ,
TYPE GS ARE % RVLCS OD UALI DESCRIPTIONLTH HUNIT VRICE COND BLDG#L/ FACT Y EY RATE V COND VALU
- AS 2,36 10 235081 OTAL OB XF VALUE � �
' GD 48 04 2157 ' �
FOP 29 03 3033
DD 37 02 735 ,
' FIREVLACE 3-1 5[ory Z�� � �
Sin le I
f OTALSA 3,51 277,04 I '
( f
� BUILDING DIMENSIONS BA5=W29WDD=N18W26511E1457E12$W12N7W14N11W23524FGD=523E21N23W21EE21525FOP=58E3�NSW37$E37N2E20N29j.
ND INFORMATION I I
HIGHEST THER AD]USTMENTS LAND TOTAL
i ND BEST USE LOCAL FRON DEPTH/ LND COND ND NOTES �� ROA UNIT LAND UNT TOTAL AD]USTED LAND IAND �
� SE CODE 20NING TAGE DEPT SI2E MOD FAQ RF AC LC TO OT TYPE PRICE UN2T5 TVP AD]5T UNIT VRICE VAWE NOTES ;
i URAL AC 0120 485 0 1.1960 4 0.9500 +00+20+00+OOr25 PW 9,300.0 7.64 AC 1.13 30,564.8 8071 RK �
PLTS �
I
OTAL MARKET LAND DATA �_64 BO��Z
I OTAL CRESENT USE DATA ��
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� http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parce1=I700000001 1/29/2013 �
, � i
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Davie County Health Department
�9��r�` Environmental Health Section .��°;;.._� �
�,,�^, � ;��,s P.O. BOX 848 . r ,.�� ..
210 Hos ital Street ` �
�� P ��,�
C'' � . �
� {� ��;, Courier# : 09-40-06 �„ ��c�;� ,
� �` Mocksville, NC 27028
Phone:(336)-753-6780 Fax: (336)-7531680
� ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: ����/'� � Phone Number (Home)
Mailing Address: (Work)
f I���i f�s(f 7� 1'(�. �G �7(��.-� Email Address:
Detailed Directions To Site: C.��5 1� � �IrIVG(Jf�Pi (Il. � �I j i��'1�
�om� D N l�� -�: .
Property Address• C J �� �C�I E'vt��
Please Fill In The Following Information About The EXIS ING Facility: �
Name System Installed Under:----���� l Type Of Facility: l 1 ��s�./
Date System Installed(Month/Date/Year): ��� � Number Of Bedrooms:�_Number Of People:��
Is The Facility Currently Vacant? Yes � If Yes,For How Long?
Any Known Problems? Yes No f Yes,Explain:
Please Fill In The F Ilowing Information About The NEW Facility:
Type Of Facility:�, ��} ��,�( 1�'�'� Number Of Bedrooms: Number of People
Pool Size: Garage Size: � Other:
�equested By: Date Requested: � /
(Signature)
. For Environmental Health Office Use Only
Approved Disapproved �
Co ts: �
Environmental Health Specialist Date:
*The signing of this form by fihe 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: Cash � Check Money Order # Amount:$ Date:
Paid By: � � Received By: �
Account#: � Invoice#: � �
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