128 East Rolling Meadow Road Lot 27Davie Countv. NC
Tax Parcel Rennrt
Wednesday, December 21, 2016
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage:
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
Land Value:
Total Assessed Value:
WARNING: THIS 1S NOT A SURVEY
Parcel Information
H9080A0027 Township: Shady Grove
5789636039 Municipality:
82513073 Census Tract: 37059-804
SIMMONS MICHAEL KEITH Voting Precinct: EAST SHADY GROVE
128 EAST ROLLINGMEADOW ROAD Planning Jurisdiction: Davie County
ADVANCE Zoning Class: DAVIE COUNTY R -A
NC
Zoning Overlay:
27006-0000
Voluntary Ag. District:
LOT 27 FALLINGCREEK FARM PHASE I
Fire Response District:
0.74
Elementary School Zone
9/1999
Middle School Zone:
003130375
Soil Types:
0007
Flood Zone:
096
Watershed Overlay:
Outbuilding & Extra
Freatures Value:
Total Market Value:
No
ADVANCE
SHADY GROVE
WILLIAM ELLIS
PcB2,PcC2
DAVIE COUNTY
All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to
NC or arising out of the use or Inability to use the GIs data provided by this website.
NTY HEALTHYDEPARTMENTG`DU
r--AlDAVIE COU
44. Environmental Health Section PROPERTY. J,NFORMATION
P.O BoK(848
Directions to property: —� s� ` ``'�'16c�CsC�i11eEINC 27028 Subdivision Name: 1
,d,.` . �r J.✓,rl Phone #: 336-751-8760 lection: / Lot:
/ AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 2421 A Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE, ISSUED by the Davie Countv Environmental 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 c T pliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
t
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t% IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENT L HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE j ! # BEDROOMS # BATHS # OCCUPANTS' v GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE r
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR Fr, -,-2:9/j
OTHER
Ripntimpn CTTR MnnTPT ATTr)NS/rnVnTTTnNS-
**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.
OPERATION PERMIT t
SYSTEM INSTALLED BY:
I�
e�
AUTHORIZATION NGL�g OPERATION PERMIT BY: DATE: / ,�p Alhv
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 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.
DCHD 02102 (Revised) �'' 33 ` /
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) �y r�
HONE NUMBER / �� !. S 7/
UBDIVISION NAME F�AL- -- (::&
LOT # �;), -7
DATE SYSTEM INSTALLED 92 NAME SYSTEM INSTALLED UNDE117::)*t` /0
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY CGLtI1 T SPECIFY PROBLEM OCCURRING 42
DATE REQUESTED (d INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
'RIZA �, '� '� DAVIE COUNTY HEALTH DEPARTMENT
�> Environmental Health Section PROPERTY INFORMATION
Imrtee,s f)�� `� P.O. Box 848
Name: ALJ ,� �I Mocksville, NC 27028 Subdivision Name:
l�f�> Phone # 336-751-8760
Directions to property: fug' �C Section:_ Lot:
�-- AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#`'�—�,
SYSTEM CONSTRUCTION
Road Name: + . 60
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This Fonn/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pen -nits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE _�� # BEDROOMS # BATHS _ # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) _ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEI-!ga—V GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH Ao LINEAR FT. oz) `
OTHER
REQUIRED, SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"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 - 1:3 P. ON E DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT .-
INSTALLED BY:
DCHD 05/96 (Revised)
f""1A'�i���'ll�v$+d,.Y.`..r+1�•'{'A''��c��.Y�@'�St:�e4'y:iR �nd.t4.i •ti+\ J
ANO. 1,787 DAVIEOUNTY HEALTH DEPARTMENT
'Environmental Health Section PROPERTY INFORMATION
� tm� to "sP.O. Box
'848
848
lame Mocksville, NC 27028 Subdivision Name:
Phone # 336-751-8760
"f
Directions to property: J'�t Section: Lot:
AUTHORIZATION FOR
-WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Road Name: 1 p: 7-906
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental 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.
(ln compliance with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
**.*NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH PECIALIST DATE ISSUED
a'y=,y"!r` s- �.a„ a •a �,.y:. .n,,.i, .r ,.. 'w ..- .....,.:_.,�,e ,rt,e +�..n.. ,� , -:. . � ,:.,�s•r , . ,., s z a. a .:.i,
h, `' ai �- zs �. a EXU
DAVIE , OUNTY HEALTH DEPARTMENT
X787
" ' IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
/t` Subdivision Name:
.. Dxxqctiolis to'property:-rr , f �'�'.?_+ `j Section: Lot:
' IMPROVEMENT
PERMIT Tax Office PIN: F�
f Road Name: fa' p: 6 e1(c
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of aseptic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCITON must be obtained from this Department prior to the
constntction/installation of a system or the issuance of a building permit:
(m compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems),'.
' ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE,;
PLANS OR.THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTIf SPECIALIST: DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
.INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE I7� # BEDROOMS _ # BATHS � # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE/% # PEOPLE # PEOPLEJSHIFT #SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY O DESIGN WASTEWATER FLOW (GPD) 3 NEW SITE v REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE OOa GAL. PUMP TANK _ GAL. TRENCH WIDTH ROCK DEPTH /P LINEAR FT: pZ)
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
DCHD 05/96 (Revised)
APPLICATION FOR SFE EVALUATION/IMPROVEMENT PERMIT & ATC D �' M
Davie County Health Department U
Environmental Health 5&Won NOV -
P.O. Box 848/210 Hospital street -61998
Mocksville, NC 27028
(336) 751-8760 EIMPnINAArArri.
I ***nWORTAItT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1
2.
Name to be Billed/✓/ Contact Person 4�YV��Q
Mailing Address ZZO--TrnA, 7`t9� Ql.r! Homme Phone �� Z / 7 -7
city/state/ZIP /,ate ,St> l n C-+ -7707-3, Business Phone
Name on Permit/ASC if Different than Above_ �/ //:Gr / /i%CO 14 Q
Mailing Address ::5 y City/State/Zip
3. Application For: U Site Evaluation �0 Improvement Permit/ATC
4. system to service: --Ca House 0 Mobile Home 0 Business 0 Industry
0 Other
0 Both
5. If Residence: # People # Bedrooms # Bathrooms o�Z
ADiahwasher 0 Garbage Disposal 31 Tushing Machine 0 Basement/Plumbing Basement/No Plumbing
6. If Business/Industry/other: Specify type # People # Sims
# Commodes
# Shovers # Urinals # Nater Coolers
IF FOODSERVICE: # Seats Estimated Nater Usage (gallons per day)
7. Type of water supply: County/City 0 well 0 Community
a. Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes A -0
If yes, what type'
***IMPORTANT*** CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either s PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
�� r , �'7C'� (� �DIRECTIONSDECTIONS (from Mocksville) to PROPERTY:
Property Dimensions: �7 (n
Tax Office PIN: # 7 b Co
Property Address: Road Namw e PK
City/Zip
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
77 R
Date Property Flagged: //-
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permits)
issued hereafter are 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 1, aLw, understand that I am responsiblefor aU charges incurred from
this application. 1, hereby, give consent to the Authorized Representative of the Davie County Health Department
to enter upon above described property located in Davie County and owned by
to conduct all testing procedures as necessary to determine the site suiytbijih•. „
DATE % SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Account No.
Revised DCHD (07/98) Invoice No. 3 1 q
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT
- Davie County Health Department
Environmental Health Section U
P O. Box 848 AUG - 61997
Mocksville, NC 27028
(704) 634-8760
**** TAN **** IS AP LIGATION CANNOT BE PROCESSE
1
IMPOR T TH P
/
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed Wyas� 4bek4e o Contact Person 61,)4
Mailing Address ,2tS 5,:aUy t Home Phone 9991- 8 4M q
City/State/Zip U; Jvs �y d .5r4 z", N e , Q 7/0 3 Business Phone 9 9 �? 6- 7
' 99�-alio.
Name on Permit/ATC if Different than Above Soa in
Mailing Address City/State/Zip
2.
3.
Application For:
4.
System to Serve:
5.
If Residence:
G Dishwasher
6.
I` Business/Other:
i
7.
8.
it Commodes
2 Sire FvAllation
❑ House
# People
❑ Garbage Disposal
If Foodservice:
7 jpe of water supply:
Specify type
❑ Mobile Home
❑ Improvement Permit & ATC
❑ Business
# Bedrooms
❑ Washing,Machine
:s
❑ Industry
❑ Basement/Plumbing
# People _
# Showers # Urinals
# Seats Estimated Water Usage (gallons per day)
❑ County/City
❑ Well
Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type? I
E
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: q9, 74f'�S 1 WRITE DIRECTIONS (from
Mocksville) TO PROPERTY
Tax Office PIN: # 7 Sq - 63 = _�s 7 4 3 ; ,
1Aw clZ
Property Address: Road Name
�m0A) 96, oto C
City/Zip AQUI4l'y�
D A/ �� enDLe� Lredd
If in' Subdivisionprovide inform tion, as follows: 1
-{�)EJ5 Vin in4—r- A Vir--� /� i oil S 1 �ro D ov .1 g �/ f -
Illy .Z — 1
'` ? 1
Seztion• Lot #• - 1
1
This . to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter
'i are 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
1 1
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by pal to conduct all testmg,,procedures
as necessary to determine the site suitability.
DATE SIGNATURE
Revised DCHD (06-96)
S J -
1
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section SECTION_ LOT.;17
Soil/Site Evaluation
APPLICANT'S NAME DATEEVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION C /C ROAD NAME
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit I---- Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Sloe %
«
i
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
"
-L 1
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 RA
REMARKS: ->& 0"
END
Landscape Position
EVALUATION BY:
OTHER(S) PRESENT:
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
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
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 (01-90)
6po
C�ti b'I
le�
96
cl
6 0 m
U)
C6 0
1101
0
0 M„00, tr 7- 0 2 N
71 26 M"OOX9.21 N
.00'6Z I
' r-4
. 90 Igs
+i
CD
0)
N
'5
409 55'
27C
�IB3'4(0027f
r-
17�_j
(:'(Iul
I .9L 92 _.9Z -J I —
4`' _Ia_ 111 Z”
0
04
Do
rcv
-
W _:)
qO'64�' 61 -:) 25.44
240046'
,88'40'b'
u
Lo
CP
Z40.00' til
C)
'n
r'4
rn
LL
240.00'
588'40'55"F
0) <
6cri
q a)! -.5
248-29' UI Cl -
S813 -40'55"E
J (0,
(14
LO
6 11
257
poi
5
!0b'
9')
C) . r
ci .4
C) C)
U
+!
'Co
�c 0
11)
04
r-.
o(A
0
fl
u
b-
Q
0
-H
00
i0
U
CN
14'
\,,C�N
0
00
C14
r-
r':
00
C14
LI)
0
r-
OEn
. 90 Igs
+i
CD
0)
N
'5
409 55'
27C
�IB3'4(0027f
r-
17�_j
(:'(Iul
I .9L 92 _.9Z -J I —
4`' _Ia_ 111 Z”
0
04
Do
rcv
-
W _:)
qO'64�' 61 -:) 25.44
240046'
,88'40'b'
u
Lo
CP
Z40.00' til
C)
'n
r'4
rn
LL
240.00'
588'40'55"F
0) <
6cri
q a)! -.5
248-29' UI Cl -
S813 -40'55"E
J (0,
(14
LO
6 11
257
poi
5
!0b'
9')
C) . r
ci .4
C) C)
U
+!
'Co
�c 0
11)
04
r-.
o(A
fl