251 Woltz Ln p�,P �.�- �
, , ., • . . , DAVIE COUNTY HEALTH DEPARTMENT
. � Environmental Health Section
, P.O.Boa 848/210 Hospital Street
, Mocksville,NC 27028
(336)751-87G0 „�L��� j��G/.�����
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Account #: 9900p1866 Tax PIN/EH#: 5779-10-4461
Billed To: John Woltr Subdivision Info:
Reference Name: Location/Address: Burton Road-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 2945
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MLTST BE ISSLTED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). T'his Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWA ONS IS VAL D F R A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signatur : Date: d
CERTIFTCATE OF COMPLETION
**NOTE** The issuance ofth' Certi c on ImprovemendOperation Permit
has been installed in comp i . . p er A,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.
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Septic System Installed By: /
Environmental Health Specialist's Signature: ��� Date: �l✓�/��/
DCHD OS/99(Revised)
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DAVIE COUNTY HEALTH DEPARTMENT P�Q �j-20��
' Environmental Health Section
� � . ' � � � P.O.Boa 848/210 Hospital Street
.' •� Mocksville,NC 27028 �
(336)75]-87G0 � �
v� �
IMPROVEMENT/OPERATION PERMIT
Account #: 990001866 Tax PIN/EH#: 5779-10-4461
Billed To: John Woltz Subdivision Info:
Reference Name: Location/Address: Burton Road-27028
Proposed Facility: ResidenCe Property Size: see map
**NOT�**Tfiibginprove�ment/Operation Permit DOES NOT authorize the construction of a septic tank system or any wastewater
system. An AiJTHORIZATION 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
Article 11 of G.S. Chapter 130A,Wastewater Systems, Section.1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type ��f�SC #People Z #Bedrooms� #Baths Z
Dishwasher: � Garbage Disposal: u Washing Machine: ❑ Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type �Q� #People y #People/Shift #Seats Industrial Waste: ❑
Lot Size � Ql:��,s Type Water Supply�� Design Wastewater Flow(GPD)��i Site: New�Repair❑
Z �r
��System Specifications: Tank Size��GAL. Pump Tank GAL. Trench Width �o Rock Depth 1'�-�� Linear Ft.�'��
1
Other: �`D�ST�..i��T(� Bp� _ �����u- l�lr`1�S �j�p•C., M,�t�,
�
equired Site Modifications/Conditions: ��TA� �►J ('����, ��P � p� �fl���J,��i�O�
IN[PROVEMENT/OPERATiON PERMTT LAYOUT- APPROVED EFFLUENT FILTER. RISER(S)IF G °�BELOW
FINISHED GRADE. ****NOTIC���...Contact a representative ofthe Davie County Health Department for final inspection ofthis
system between�:30 a.ml,c;tl�'9:30��i. or 1:00 p.m.to 130 p.m.on the day of installation. Telephone#is(336)751-87G0.�***
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Environmental Health Specialist's Signature: �� �! a 1
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DCHD OS/99(Revised)
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' • � �'C� � � � M [� w`'�
CATION FOR S17E EVALUATION/IMPROVEMENT PEiiM1T&ATC
' Davie County Health Department
A�� I ZOOI Environmenta/Hea/th Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
- ENVIR�pAVIE COUNT�1'�LTH (336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFOF2L�TION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. �
- 1. Name to be Billed��� ��_(�� �1 V(7 I�C_ ��• Contact Person VO�� ��� `�v v v��
Mailinq Address �� v Y � Home Phone �L,� �"�.J
City/State/ZZP W� � Ivl� � � Business Phone Tl(J� ��p 1
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: C�Site Evaluation �mprovement Permi.t/ATC �1 Both
a. system to sezvice: [9'House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. if Residence: # People /,� # Bedrooms 2, # Bathrooms 2.
fiYDish�rasher i arbage Disposal fYWashing Machine ❑ Basement/Plumbing CI Basement/No Plumbing
, 6. If Business/Industry/Other: Specify type M People # Sinks
1k Commodes # ShoNers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage �gaiions per day) ,
7. Type of water supply: ❑ County/City lYWell ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ��
If yes,what type?
***IMPORTANT***CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUCSTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMI77'ED by the ciient with THIS APPLICATION.
�
Property Dimensions: W RI'CE DIRECI'IONS(from Mocksvillc)to PROPGIi'CY:
r Tax Office PI1�I: # 5 1 �� � (�� "'1 (D , i') - , 5 1 �'`" ��" V`� ^� �
p �-e � -Cl. -��RC,
Property Address: Road Name-.��f a tJ � • � 1 ��' � S
•�. 3 r-�s p c�--►- �-P`f���
City/zip �p r X �'�
lf in a Subdivision providc information,�as fa!➢flws: � lrZ- r''`'u- � On ��'`��'��
� " Z�3o `' dS �G✓�' t,+Z- L-`"`L
lYame:
. F-t K C K `� f/"'O u t(S 1`"
Section: Block: Lot: Date Property Flagged: � � �a-��q
This is to certify that the information provided is correct to the best of my knowledge. 1 understand that any permit(s)
issued hereafter are subject to suspension or revocation,if the sitc plans or intended use change,or if the information
' submitted in this application is falsified or changed. I,also,understand that I am respoirsible for u/!c/larges iircutred from
Jhis application. I,hereby,give consent to the Authorized Representativc of the D vic Count caltl� Depia^rt/mc t
to enter upon above described property located in Davie County and owncd by �(��� ��� � V V�����i,
to conduct all testing procedures as necessary to determine the site sui ' ity.
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DATE �� 1 I� � ' SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Includc all of thc follo ing: Existing and proposcd
property lines and dimensions, structures, set6acks, and septic locations).
Site Revisit Chargc
O��lU l l I '. °Y '�? Datc(s):
���'-- Client Notitication Date:
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✓ J �-Y' � r,,�rS
��,�,,, . �o�"�`� Account No. b .
Revised DCHD(07/99) �� ���� Invoice No. �— � `� �
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"n�w _ SCALE• ' /��= �o' qPPROVED BY DRAWN BY
. DATE: !a -L9-95
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�'�"'��'°K 0 0 3'7 9
�• �• .�;�ro: John Elliot�Woltz, Jr.,
. ,� •� WARKANTY DEED—Form WD-601 Printed and for sale by James Williami h Co.,Ine.,Yadkiriville,N.C. �
STATE OF NORTH CAROLINA, ' Davie County.
aTHIS DEED,bt,de�his 2-$ day oE Julv ,19 95 ,by and between Howell W. Woltz and
* o� Davie co��ry
t _ind state of Nocth Cuolina,hereinafcer called Grantor,and John ElliotE Woltz, Jr.
i�� Davie
� a( County and S�ate of North Carolina,hereinaCter
y alled Crantee,whose permanent mailing address is
WITNESSETH: That the Grancor,for and in consideration of the sum of TBn and 00,[l�� Dollare
d othec good and valuable considentions to him in hand paid by the Grantee,the reeeipt whezeoE is hereby acknowledged,has given,granted,bargained,sold
pnd conveyed,and by these presents does give,grant,bargain,sell,convey and conC�rm unto the Grantee,his heirs and)or suc<essors and assigns,premisa In
m Shady Grove Township, Davie County,North Cuolina,described as follows:
a
W
o BEGINNING at a point an iron pin lying on the Western bank of the
Yadkin River, said point of BEGINNING being the original Northeast
corner of that Tract designated as Tract One described in Deed Book '
157 at Page 481, Davie County Registry, and being the Southeast
corner of Russell M. Howerton, Deed Book 179 at Page 769, thence
� from the point and place of BEGINNING (which is the Northeast
i�� corner of the within described tract) with the bank of the Yadkin
- �• River South 18 deg. 28 min. 41 sec. West 427.64 feet to a point and
�i South 03 deg. 54 min. 59 sec. West 320.07 feet to a point,
Southeast corner of the within described tract, thence a new line
�' with Howell W. Woltz North 88 deg. 46 min. 47 sec. West 2379.35
=; feet to a point in the Eastern boundary of the J. V. Peebles Estate
i•� (Clerk's file number 83-E-1) , Southwest corner of the within
�� described tract thence with the Peebles Estate North 06 de 33
i� � g•
': min. 03 sec. East 731.27 feet to an iron pin lying in the Southern
c�.� boundary of James T. Whelan (Deed Book 162 at Page 189) , said point
� being the Northwest corner of the within described tract,• thence
� with Whelan South 88 deg. 47 min. 40 sec. East 170.02 feet to an
a iron pin, thence with Garland V. Myers (Deed Book 96 at Page 485),
F.- South 88. deg. 47 min. 39 sec. East 680.43 feet to an iron pin,
o thence with Howerton South 88 •deg. 46 min. 55 sec. East 1602.98
. `' feet to the POINT AND PLACE OF BEGINNING, containing 40 acres and
being the Northern portion of Tract One described in Deed Book 157
• at Page 481, Davie County Registry. Said Tract is also described
as �a part of Parcel 6, Davie County Tax Map I-9 dated March 28,
1976.
For back title see D��� ,���o;FE�CHct'��age 481, Davie County
Registry.
DATE �- .�'J-�I G U��. �' ✓/� ,
The above land was conveyed to Grantor by �"K"��`"'"' '�.See Book No. Page .
TO HAVE AND TO HOLD The above described premises,with all the apputtenancn thereunto belonging,or in any wise apQertaining,unto the Grantee,his
he'vs and�or successors and assigns forever.
And che Grantor covenants�hat he is seized of said premises in Cee,and has the right to convey the same in Cee simple;that said premiscs are free Erom en-
cumbrances(with the exceptions above sated,if any);and that he will war r a n t and defend the said title to the same a ' st the lawful claims of all petsoro
whomsoever.
Whe efe �ce is made to the Grantor or r ee,the singular shall include the plural � e masc ' e shall n de th fe in or the neuter.
SS /��/,(�Th nt er set his hand and seal,the day and st ov ricte .
HO 211 W. WO1tZ (SEAL) ernice�I O Z (SEAL)
(SEAL) (SEAL)
STAT NORT1H CAROLINA - PS .
1, �1� �' ;X pu ie of said County,do hereby certiEy that
Howel z c�' . Woltz
Grantor,personally aQpeazed before me this d a �owledged�,��,��rego g deed.
• Witness my hand and notarial seal,this the `7�' ,19 95.
My Commission Ezpires: . — ,N.P.[SEALJ
STATE OF NORTH CAROLINA COUNTY.
� - --- •— ----�----- — -•="�eca�.o�b!'aeE_:dC_.. ,..i_�....�.._. .:t.�.w.�--. -------• --
_ . _ . .._- ----'--.—_'.----� �---- -..__.——'..----
Grantor,personally appeared before me this day and acknowledged the execution oC the Coregoing deed.
Witness my hand and no�arial seal,this tho day of ,19—.
My Commission Exp'ves: ,N.P.[SEAL]
STATE OF NORTH CAROLINA, �vle COUNTY.
The foregoing cer�ifute�f)of ph���i G p �O�"i11�n �OtdT'v �11�11.0 of Forsyth County
a}{g;):llfied to be correcc. This instrument was presented Cor rogistration[hu 29� day of `7an�'Y ,19—,
at � �.Mf,P.M.,and duly recorded in the office of the Regiscer of Deeds of Ik3V12 County,
North Carolina,in Book �-HS p'g� 214�
This the 29� day oE '7an� .A.L.,19 96. !�,_�� J
f�II2Y L. SHORE nY J��
Regis�er of Deeds �j33dp{�f1�t�Deputy Regiscer oCDeeds
T}��s Dced drawn by Grady L. McClamrock, Jr., PO Box 1144, Mocksville NC 27028
� .:..a.. w. . . .. ::�r.. �"�-,� ..__�::..d t_' —
. , . ..�n RaX -
• = . O O.3�n DEED BOOK�_pAGF��S
Easement Agreement
This Z S� day of�, 1995,be it Irnown that:
This agreement between Howell W.Woltz nnd wife,Vernice C.Woltz of Davie
County,hereafter called the Grantors,and John Elliott Woltz,Jr.of Porsyth .
County,hereafter called Grantee,is for the purpose of granting an easement for
egress and regress to and firom certain properties conveyed from Grantors to
Grantee,specifically,the northcrn 40 acres of P�rce16,Davie County Tax Map
I-9,dated March 28, 1976.
Grantors give full rights and access to Grantee of their 60 foot easement firom
- -theirproperty to State-Highway SR 1646 recorded�itrBbok 80,-p�ge 97;Davie `"" -'� " "� "'
Cownty Registry.
Furtheriuore,an easement across the western pordon of Parcel 6,Davie County
Taac Map I-9,dated March 28, 1976 for access across portion being retained by
Grantors,is aclatowledged.This easement will specifically be a 60'wide right of
way along the western edge of said parcel.
In witnes whereof,The Grantos have hereunto set tt�eir hand and seal,the day
and year first written above.
C`J tX�'o��
owell W.Woltz(Sea Vernice C.Woltz(Seal)
State of North Carolina ,��[�rsv`�1 County
I, � �11���1 � l'�O ���Yl n • ,a Nota�ry Public of said County,do hereby
certifythat o<<� .Il lt1. l��1� r�d Vemiee C..l�)nl'�'� , .
Grantors,personally appeared befo the
execution of the foregoing deed. �,�q�
J �FF�•C'AATH GIROUNA
r Qf SYfH
Witness by hand and notarial seal, �i�� ,
I995. ��B�o@�1 ta 19a�
My cominission expires:l 9 1(1T� ( O , ��`-1 .P.(Seal)
This instnmient prepared by: Howell W. Woltz
NOF2TI-I CAF20LiNA.DAV[E COUNTY
'� Ph llis P. Bowtnan �
Theforegoing certlIlcate f�3 of...........X.....................................................................................................................................
..........................................................................................................................................Notary Public}�s)of.k.�s.�..`.'..•..........County
Is(�;S)certl(led to be correct.Th1s fnstrument was presented for rcglstratlon thls......2�tYl.....day o(......JdLlllcL�.]Z................is..9fi...,
at.�,.;�.�......AC2�'?(P.M.,and duly recorded!n the ofllce of the reglster of Deeds of DAVIE COUNTY,North Carollna In Book....185. ,
215
Page.....................
Thls the ...........���lday of......�.dAl]�'y...........................A.D., is..9�..........
Henry C..Shore IIy:..`�...7 l.1.��`•""`'��!SGa����'/r`''�'.`.�
...... ...............................
REGlSTER OF DEEDS Ag9iS�GDEPU7Y FtEGISTCR OF DEEDS
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.� � DAVIE COUNTY HEALTH DEPAR'I'MENT
` � •� ' � + � � Environmental Heaith Section
= • Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990001866 Tax PIN/EH#: 5779-10-4461
Billed To: John Woltz Subdivision info:
Reference Name: Location/Address: Burton Road-27028
Proposed Facility: Residence Property Size: see map Date Evaluated: � I� ��
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landsca e osition L
Slo e% �
HORIZON I DEPTH Q.
Texture rou `� S:CL s'
Consistence S s r
Structure G
Mineralo `
HORIZON II DEPTH .F
Texture rou $C �
Consistence �
Structure
Mineralo :� �•
HORIZON III DEPTH � 1
Texture rou
Consistence ,• 5 `S
Structure +
Mineralo � Mt �,
HORIZON IV DEPTH l 1 -
Texture rou
Consistence �
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE Q.
SITE CLASSIFICATION: PJ EVALUATION BY: V� ��-�''�
LONG-TERM ACCEPTANCE RATE: �' OTHER(S)PRESENT: �-_� ����
REMARKS:
LEGEND
Laadscape 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
Mineraloev
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-gal/day/ft2
DCHD OS/99(Revised)
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