1227 Woodward RdDavie Countv. NC � . '
Tax Parr.el R ennrf
Tuesdav. October 11. 2016
WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number: G40000001101 Township:
NCPIN Number: 5830032607 Municipality:
Mocksville
Account Number: 71456000 Census Tract: 37059-806
Listed Owner 1: STREET AVERY E Voting Precinct: NORTH MOCKSVILLE COUNTY
Mailing Address 1: 1227 WOODWARD ROAD Planning Jurisdiction: Davie County
City: MOCKSVILLE 2oning Class: DAVIE COUNN R-A
State: NC Zoning Overlay:
Zip Code: 2702&5864 Voluntary Ag. District:
Legal Description: 1.73 AC WOODWARD RD Fire Response District:
Assessed Acreage: 1.78 Elementary School Zone:
Deed Date: 1/1988 Middle School 2one:
Deed Book / Page: 001410585 Soil Types:
Plat Book: Flood Zone:
Plat Page: Watershed Overlay:
Bullding Value:
Land Value:
Total Assessed Value:
9"�`�' Davie County,
°��„�� NC
137230.00 Outbuilding 8� Extra
Freatures Value:
23800.00 Total Market Value:
161030.00
WILLIAM R. DAVIE
WILLIAM R DAVIE
NORTH DAVIE
Gn62,EnB
DAVIE COUNTY
161030.00
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Da�ie County Health Department
�P bf� Environmental Health Section
�� : � P.O. Box 848
� � ,�,5„ ` � � � � � � 210 Hospital Street
O � �'S. :k:� Courier # : 09-40-06
�� OCT � C 2012 ocksville, NC 27028
Plione: (336) - 753 - 6780BY: ��^�T r'*�'T' vJASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
F�: (33G) - 753-1680
Name: ' '� �ti' e - ir�� Phone Number �� ��� 7� (Home)
Mailing Address: ��Z� %�(�d [� (��%'L/'1^� � (Work)
���r;/tsu �I /e �I/C 2Zv� Email Address:
Detailed Directions To S
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: ���i ,,� �� Type Of Facility:��V/�
Date System Installed (Month/Date/Year): � ' Number Of Bedrooms: � Number Of People: �
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any Known Problems? Yes � If Yes, Explain:
Please Fill In The Following Information About The NEW Fac ty�� a,z(,
Type Of Facility: ��l/Pi iG�GI/�U/��-�' �U��.pa(� lLxs��i Nd er Of Bedrooms: Number of People
Pool Size:
Size:
Other:
xRequested B�:— �� �� , � _ --�t��.�r5�- XDate Requested: %� ��� ��z
(Signature)
,
Approved Disapproved
Comments:
Environmental Health Specialist
For Environmental Health Office Use Only
Date: 1(% �� ��
*The signing of this form by the Environmental Health Staff is�(n 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 #,
Paid By
Amount:$
Received By:
Account #: Invoice #:
Date:
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. DAVIE COlR1TY HERLTH DEPRRTMENT
� , � � IMPROVEMENT PERMIT and OPERRTION PERMIT
IP�RDVEMENT PERPIIT � '
�N�OTE�� This i�prove�ent per�it DOES NOT authorize the canstruction or installation of a septic tanq syste� or any wasteHater
syste�. RN RUTHORIZATIDN FOR IJRSTEfJATEA 5Y5TEM CDNSTRUCTI�1 �ust be obtained fro� this Depart�ent prior to the
construction/installation of a syste� ar the issuance of a building per�it.
(In co�plian�e with Article i! of 6.5. Chapter 130A, WasteNatar Syste�s, Section .1900 SeNage Treat�ent and Disposal Syste�sl
IJRME �'�!/�� ,.� f �CPs ! PflOPERTY RDDRESS `�i�Ji)iJ<'�.'),( �C� rC1— I�'L�._ ." �/�� a�i c} DATE ��i'n.'"
LOCRTION �.�I%/JO�Tl.�'/s9'r�
SUBDIVISION NRME LOT MA�ER _ SEC./BLDCK NlA�1BER
i �
RESIDENTRL SPECIFICRTION: BUILDING TYPE ,/�'�d.�{ # BEDROOMS � 1 BpTHS �S t OCCUPRNTS � 6ARBAGE �ISP05f3L: Yes/No
COMt�RCI{K. SPECIFICRTION: fRCILITY TYRE 1 PEDPLE � PEDFtE/SHIFT 11 5ERT5 INDUSTAIRL WASTE: Yes/No
LOT SIZE �G TYPE WATER S�PI.Y �'C� DE5I6N NRSTEWATER FLON ffPD) ��/1 NEN SITE ii' REPAIR SITE _
SYSTQI 5PEC1fICATIDNS: TAr9( 5I2E � 6AL. F{,R6� TiMBI 6RL. TRENCH WIDTH -3�� ROCN DEPTH /7 J/ LIt�EAR fT. �
OT}IER
REf�UIRED 5ITE MODIFICATIDMS/CONDITIONS:
#+;THIS PERMIT I5 SUBJECT TO REVOCRTION IF SITE PLHN5 OR TNE INTENDEU USE qif�1GE. YOUR IJHSTERI�ATER SYSTEM CONTRRCTOR MUST
SEE THIS PEAMIT BffORE INSTALLIN6 THE SVSTEM.
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IMPRDUEMENT PERMIT BY /'v6'� /f
f+FC�1TACT A REPRESENTATIVE OF THE DAVIE (Xri�ITY HEALTH UERFIRTMQtT FOR FINRL INSPECTION OF THIS SVSTEM BETtiIEEN
B:30-9:30 A.M. OR 1:�-1:30 P.M. ON THE UHY OF INSTALLRTION. TEtEPHONE i IS 17041 634-8760.
OPERATION PERMIT
SYSTEM IN5TRLLED BY /� �iG�c.7 j%�J��$Di✓
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AUTHORIZATION N0. ?}oZQ'l� OGERATION DERMIT BY
mTE S ' 6 -9P`
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+�THE ISSURNCE OF 7HI5 OPERATION PERMIT SHALL INDICRTE T}IAT THE SYSTEM DESCAIBED ABOVE HRS BEEN INSTRLLED IN COMPLIRNCE WITH
AATICIE 11 OF G.S. CFI�PTEA 130A, SECTION .1900 "SEWA6E TitEATMENT pND �ISPOSRL SYSTEMS°, BUT SI#iLL IN NO WAY BE TWIEN �.S R
l#JARANTEE THRT THE SVSTEM WILL FlINCTION SATI5FACTORILY FOR RNY 6IVEN PERIOD OF TIME.
. ,. _ .._, .. ;. ,._.. - ._.._ y✓co
,. �
IMPRDVEhIENT F�ERMIT
DRVIE CDUNTY HEflLTH DEPARTMENT
IMPROVEMENT PERMIT and �EAATION PERMIT
+��NDTE�� This i�prave�ent per�it DOES NOT authorize the �onstruction or installation of a septir tank syste� or any NasteNater
syste�. RN RUTHORIZATION FOR WRSTEWATER 5Y5TEM CDNSTRUCTIUN �ust be obtained fro� this Depart�ent prior to the
construrtion/installation of a syste� or the issuance of a building per�it.
(In co�pliance with Article 11 of 6.5. Chapter 13QA, Nastewater Syste�s, 5ection .1900 5ewage Treat�ent and Disposal 5yste�s)
NAME �� l/�/'v1 ��t'�i / PRDFERTY ADDRE55 `7��()0�=1�( �Gk_ 1rC�L. !\� •~ � r�� � " DATE '�`i ' ,
LOCATION �/D/� /�'/A�/�
SUBDIVI5IDN I�ME LOT M�IBER 5EC. /BLDp{ M�iBER
i � m
RESIDEI�ITAL SPECIFIC�TION: BUILDING TYPE /�<:� � BEDR�MS �� BATFIS �3 # OCCIIF'ANTS � 6ARBf�E DISP05Al.: Yes/No
CDMMEREIRL 5PECIFICATION: fACILITY TYPE � PEDRLE � PEDF�LE/SHIFT # SEATS INDUSTRIRL NASTE: YeslNo
L�T SIZE r ; C TYPE WpTER SUPPLY �'U DE5I6N I�STEWATER FLOW (GPD1 . S�'t'./% NEW SITE � REPAIR SITE
5Y5TEM SPECIFICA7I�IS: TANI( SIIE iY'i� 6AL. WJMP TAhd( 6AL. TRENCH WIDTH ?../� R�K DEPTH ,f_` LII�AR FT. .�:' �
OTHER
REQUIRED 5ITE MODIFICATIINJS/LXINDITIDNS:
���TNIS PERMIT IS SIIBJECT TO REVOCATI�I IF SITE F'LAN5 OR THE INTENDED 11SE CHANGE. VDUR WpSTEAWATER SYSTEM CONTRACTOR hN1ST
5EE THIS PERMIT BEFORE INSTALLIM6 THE SYSTEM.
�����'�'
IMPROUEMENT PERMIT 9V /�t�i� /�
"��CONTACT A REPRESENTATIVE � THE QAVIE C�1TY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM RETWEEN
8:30-9:38 A.M. OR 1:�-1:30 P.M. ON TF� DAY OF INSTALLATION. TELEPHONE # I5 t7�4I 634-87E@.
OPERATION PEAMIT
s�
SYSTEM INSTALLED BY ��G��� %Yi��Or✓
a�� �'r``'°�`��- Z � o' � �� �
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AUTHORIZATION N0. ?ja�� OPERATI�1 PE�IT BY
DCHD 10/95
DATE S — b "e� p'
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Davie County Health Depart�ent
' ENUIRONR9ENTRL HEALTH 5ECTIDN
P.n. eox ��s
Mocksville, N.C. 2702b
AUTHDRIZATIOi! FOR WASTEWRTER SYSTEM CONSTRUCTIQ!
fIssued in co�plianre with Article 11 of
G.S. Ghapter 1s0A, Wastewater Systeis)
�6
.�s�"��
���,� �
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+��*This Rutharization For Waste►+ater 5yste� Construction �ust be issued by the Davie County Environ�ental Health 5ection prior to
issuance of any Building Per�its. This For�/Ruthorizatian Nu�ber should t,e presented to the Davie County Building Inspections
Offire when applying for Building Per�its.+��
,� � AUTFDRIZATION t�ER
NAME �,�7t,'r.''�` v� �,/lP�' � DATE �/-, /�—G'� r',� ° �i � � .',
NRME ON IlPR04EMENT PERMIT (If different than above) :
SITE LOCATI�N �i�'l,u�/G�' �/_� �
COMI�ENiS/CONDITIWS ON AUT}IDRIZRTION TO I:ONSTRUCT I�ASTEWATER SYSTEM
��TICE� TH15 AUTHDRIZATIDN FDR Wfl5 RTER SYSTEM CDN5TRliCTION IS VALIO FDR A GERIOD OF FIVE {5) YEARS.
/ l/ /�� '�-`� -��,/
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ENVIRON�ENTAL FfALTH 5P�CIALIST ' DATE
DCHD 10/95
• , , , � APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
• i Davie County Health Department
. Environmentai Health Section
P. O. Box 665
Mocksville, NC 27028
�t;� l5 M I t'� �
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1. Application/Permit Requested By t��ir't��/ C• ��V' r" `e �
Mailing Address ��� �� h a l� (� � Home Phone �'f� rl — 7� lr`6'� ��' 3
��,��� zr�'%1� �, �', � 70� � Business Phone 9��—I��"���3
2. Name on Permit if Different than Above
3. Application for:
❑ General Evaluation
4. System to Serve: �ouse
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
No. of Bathrooms G
Dwelling Dimensions � 2 �� �
�eptic Tank Installation Permit
❑ Mobile Home O Place of Public Assembly
❑ Other
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes
No. of Lavatories
No. of Showers
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: ❑ Public C�Private
8. Property Dimensions � 1� 73K 2c, . Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Unknown
Section Lot #
C�BasemenUPlumbing
❑ BasemenUNo Plumbing
C�' Washing Machine
[�Dishwasher
❑ Garbage Disposal
❑ Yes G�' No
O Communiry
*NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
(00 I I�i � .
l�• CA�ntF� �I oc�.
�- Wocx�wa�cQ �i d •
SSf �4� �- � s} b�;�k ho�� o u�.
� lx�wa�n) 'i'�,c Z gr�c.iC kiouSes�.
PROPERTJ IN�OIZMATZON REQUZIZEb:
Tax Of f i ce PIN: # �''g_�/} - D,3 - Z�� C? �
PIZOPERZJ Abb1tESS, as follows:
Road Name: '�'��.Q�����
city: j�yj,��_k�r,' ll _ IVe
SU$MZT tl PLAT WZTH THZS APPLICAT20N.
Revisions effective October 1� 1995.
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
` � ;O /. /�i9G� � =�
ATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: �. I OWN the property. ❑ 2. I DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie Coy�?ty He Ith Department to enter upon above described
property located in Davie County and owned by � _�' J� e�
to conduct all testing procedures as necessary to determin said site's suitability for a ground absorption sewage treatment
and disposal system.
� � ,L � � � ��
� � �� DATE/� —� SIGNATURE
pCHD (1/93)
� ' � r ' ' � ' ' ' DAVIE COUNTY HEALTH DEPARTMENT
. - Environmental Health Section
Soil/Site Evaluation
NAME S��L� � DATE EVALUATED ���b ��
ADDRESS PROPERTY SIZE �e �/IG
PROPOSED FACIILTY LOCATION OF SITE �/EJlt�l�i�if� ,��
Water Supply: On-Site Well _ Community Public t�
Evaluation By: AugerBoring // Pit Cut
Far.TORs 1 2 3 4 S 6 7 �
Landsca e osition �- .L.
Slo e R
HORIZON I DEPTH '-
Texture rou
Consistence
Structure
Mineralo
HORIZON II DEPTH 3 L�� � r
Texture rou �
Consistence �
Structure C /C
Mineralo �, ' /
HORIZON III DEPTH
Texture rou
Consistence
Structure
Mineralo
HORIZON IV DEPTH
Texture rou
Consistence
Structure
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
CLaSSIFICATION
TANCE RATE
SITE CLASSIFICATION:
EVALUATED BY:
LDNG-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 �:lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR- Vc.-y friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
Wet
NS-Non sticky SS-Stightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic
5tructure
,iC--Sin�le grain M-Massive CR-Crumb GR-Granular ABK-AnQular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mi nerala�cy
1:1, 2:1, Mixed
Notes
Eiorizon 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 watef 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/ftz
DCHD(01-901
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