189 North Hazelwood Drive Lot 16Davie Countv. NC
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Tuesday. January 10- 2017
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:
WARNING: THIS IS NOT A SURVEY
Parcel Information
J7080B0016 Township: Fulton
5768114872 Municipality:
15744000 Census Tract: 37059-804
CLEMENT JAMES THOMAS Voting Precinct: FULTON
189 HAZELWOOD DRIVE Planning Jurisdiction: Davie County
MOCKSVILLE Zoning Class: DAVIE COUNTY R-20
Land Value:
Total Assessed Value:
NC
27028-7164
LOT 16 HERITAGE OAKS PHASE ONE
0.68
8/2004
005680538
0007
005
Zoning Overlay:
Voluntary Ag. District:
No
Fire Response District:
FORK
Elementary School Zone:
CORNATZER
Middle School Zone:
WILLIAM ELLIS
Soil Types:
GnB2,GnC2
Flood Zone:
Watershed Overlay:
DAVIE COUNTY
Outbuilding & Extra
Freatures Value:
Total Market Value:
Cpm �FAll
Davie County,
data is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the
NC
County of Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to
o� N�
or arising out of the use or inability to use the GIS data provided by this webstte.
Account #: 990002859
Billed To: Titan Homes
Reference Name:
Proposed Facility: Residence
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
/e, I-, -) -a �)
Tax PIN/EH #: 5768-11-4872
Subdivision Info: Heritage Oaks Lot # 16
Location/Address: 189 Hazelwood Drive -27028
Property Size: 3/4 acre
ATC Number: 3550
**NOTE** This 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
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 #People ! #Bedrooms #Baths_
Dishwasher:X Garbage Disposal: ❑ Washing Machine -,21J Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply C'7o Design Wastewater Flow (GPD) Site: New PT" Repair ❑
System Specifications: Tank Size Id60 GAL. Pump Tank GAL. Trench WidthRock Depth -02 Linear Ft. Z'U()
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
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)751-8760.****
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT P
Environmental Health Section
P. O. Bog 848/210 Hospital Street
MockvAlle, NC 27028
(336)751-8760
Account #: 990002859 Tax PIN/EH #: 5768-11-4872
Billed To: Titan Homes Subdivision Info: Heritage Oaks Lot # 16
Reference Name: Location/Address: 189 Hazelwood Drive -27028
Proposed Facility: Residence Property Size: 3/4 acre
ATC Number: 3550
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST 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 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONS TR CTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: Jl'
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
�l
�1
Septic System Installed By: r 1
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
' P. O. Boz 848/210 Hospital Street
' Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002859 Tax PIN/EH #: 5768-11-4872
Billed To: Titan Homes Subdivision Info: Heritage Oaks Lot # 16
Reference Name: Location/Address: 189 Hazelwood Drive -27028
Proposed Facility: Residence Property Size: 3/4 acre
ATC N nbrr: 3550
**NOTE** is mprovement/Operation Permit DOES NOT authorize the construction of 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
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 �� #People 1' #Bedrooms_ #Baths�i
Dishwasher:, Garbage Disposal: ❑
Commercial Specification: Facility Type
Washing Machine -fl Basement w/Plumbing: ❑ Basement/No Plumbing: ❑
#People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply Design Wastewater Flow (GPD) Ak�— Site: New E Repair ❑
System Specifications: Tank Size% GAL. Pump Tank GAL. Trench Width &` Rock Depth %Z Linear Ft � r
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
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)751-8760.****
Environmental Health Specialist's Signature: / Date:'%!`
DCHD 05/99 (Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 990002859 Tax PIN/EH #: 5768-11-4872
Billed To: Titan Homes Subdivision Info: Heritage Oaks Lot # 16
Reference Name: Location/Address: 189 Hazelwood Drive -27028
Proposed Facility: Residence Property Size: 3/4 acre
ATC Number: 3550
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST 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 11 of
G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEWATER CONNC
ION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: -S,
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
Septic System Installed By:
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
rr
pL1G-11-2093 19:13p FROM:KEAIEDY 9222267
TD:I-i3675IB786 p:2.'2
A! PUPATION FOR SITE EVALUATIONJIMPROVEAlMY Pulhlrl' & All;
Davie County Health Department
Epvironn7en4711fW1d1 Section
P.O. Box 848/210 Hospital Street
I•focYsville, NC 27028
(336)751-8760
***XMPORTAP7T*** THIS APPLICATION CaMOT BE PROCESSED UNLESS ALL 'XIII: RLQUIRLD
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed �L fl'zµ',,�L3"1'�'te Jam'` contact Person-'ll_•JQfYt�r�
hailing As
ddres 13TS ,�l yn.f5 rvl rl nomc Phone 33(o-94s-t{teo3
city/State/zIP jM;r%%ibn- SiAIW'0 MC a."il Ot} Duniness P 3%- 3gIR'M-.-
2. Ramo on Permit/ATC it Different than Above
Nailing Address City/State/Zip
7. Application For: &'Site Evaluation • ❑ Improvement Permit/ATC ❑ nowl
f. Syotem to Service: 23 House ❑ Mobile liome ❑ Business ❑ Industry ❑ Other
S. Type system requested: Id conventional ❑'Gonvcatioual modified ❑
umovativc
G. I.,f// Residences t People 4a Bedrooms �•_ • i Bathroans
QDiahwasher ❑Garbage Dispooal 'washing Machin ❑Basement/Plumbin< -
� � ❑Dascmcnt/No r.l uwbing
7. If Buainoss/Industry /Other: verify type B People
M commodes I Showers I urinals
B lister enolcrp
IF FOODSERVICE: 0 Seats Estimated Water Usage lgallona per day)
a. Type of water supply: L9"County/City ❑ Well ❑ Conuuunity
9. Do you anticipate addition, or Clpa lSious of the facility this system is intended loserve? ❑ Yes 1344\u
Ifycs, it (ype?
'**IAIPORT.4A'P**CLIENTSAJOSTCDAIPLCTCTj1EREQUIRED PROI'E1f1Y)WORMATtON11EQUEYI•11) I
BELOW. L•'iihcraPLATorSITE PLAN AIUSTBESU/1A117TCObythcclicut with'1111SAPi'LICATION. 1
- 1'`ropert) llimensiousr 128 ,� 23R +< I Zc� 2`f6 WRITE DIRLCI'IONS (h mitt aluchsvillc) l0 14(ol,VI IN:
Tax office PIN: it57("01 1�$7 2 t —i� b _
PropertyAddress: RoadNanic W1 -kUkkkA bl"-• nla"Or
V kLMI !N--(lk a h
Citymp ti(O(If1VtiN1� _ cilUtt� {�l(�� @P(4 (${.t.r6,(�
1f in a Subdivision providefuforiltalion, as fullolys: ��
Nalue• tvx tk � OaJL r
Section: Block: Lot. - {�i Date home corners flagged:
This is to certify that the iuforn)ation provided is correct to the bat ofjoy knowledge. I understand thatany pennil(s)
issued hereafter arc subject to suspension or revocation, tribe site plans or inteuded use change, or if flit informalion
submitted in this application is fabificd or chauged. 1, also, understand l/jot t run responsiblefur all c/mrbes hicunrd fiwin
this application. I, ficrcby, give consent to file Authorized Itepresentative of the Davie County 11c:11411 Dcpar11111 al
to cuter upon above dcsrrIbcd properly located in Davie Couuly and olrncd by
Io cunducl all testing procedures as necessary to delcrusinc the site suitaWily.
DATE ��'(73 SIGNATURIia. `A�•+(udT1sV►+eQi
T'IiIS AREA MAYBE USED FOR DRAWING YOUR SITE PLAN (Include all or the following: Existing and 111-011"ed
property lines and dimensions, structures, setbacks, and septic locations).
:Site Revisit Charge
Dalc(s):
Client Notiricatioll Date:
MIS
Sign given Account No.
Revised DMID (05/03 invoice No. �
IIJ
610 1
000,
41�F�jgl
DAVIE COUNTY HEALTH DEPARTMENT
' •' Environmental Health Section
• Soil/Site Evaluation
NAME �` u : /11IJ
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITEyN�
Water Supply:
On -Site Well
_ Community
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS
1 2 3 4
Landscape position
L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture groupC',
G
Consistence
Structure
C C
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: 46 EVALUATED BY: Z& /
LONG-TERM ACCEPTANCE RATE: I 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- V+:. -y 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
.3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
MineralORY
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 (01-901
08/12/2093 09:37 RE/mAX -) 80GP7518786 140.009 P02
AITUCATION fUli SITE EVALVATIDN/t,11P11UVEAIENT PEItkli f SAX
Davie County Health Department
&Yiraninenta/Hea/lh SeCM011
P.O. Box 848/210 Hospital Stroot
Mockoville, NC 27020
(336)751-8760
v*•IMPORT.INT•ra WIS APPLICATION CANNOT B$ PROCESSED IRiUSS ALL Pill; REQUIRLD
I;FORMATION IS PROOVIDED.. Refer co tho INFORMATION BULLETIN for in3tl:uCtioJ1J.
1. Natty to bo gilled T1TLPl tibme S Contact: 1'oramt .LUa+.k_JafW 1
Mailing Address uulc $w f4k,46 nano Phone 330 •9VS:i{foloJ .,,
e/ey/state/zlP V- r"Otw, '5dw. W- a'110 Duaineuo Phone 336 3 1 24i.
2. nae+o on Pormlt/ATC if Different than Above
Mailing Address City/Stace/zip
3. Application For: W31te Evaluation ❑ Improvoment Permit/ATC D Dotll
4. syactie to service: 2 1110uao ❑ Mobile Home 13Buain"s ❑ Industry 11Otller
S. Type ayateik reque/
oted: fid Conventional ❑ conventional nodltlod ❑ innovative
c. If Rasidonce: o Peoplc 4 1 Bodrocmo 6 Dathroa+la Y7-
tJDlshrasher ❑Garbage DLpoeal Washiag ilaehino ❑Dastftnt/Plu++biay ❑ua_ra+cnt/:lo Pl.wnbinry
7. It Dvoino:o/Iaduatry /ochor: verity typo P 1'uoplo tl :aUr.7
I Cool -deo 6 showers 6 urinalo Y Mater Caoleia
IF FOODSMVICE: 0 Seats Eatiniatod Wator Unago tgallona per dayl
11. Typo of Nater supply, 13/County/City U Woll ❑ Caranunity
s. Do you anticipate a4ditiona or cxpansious of the facility this systein is intender] to serve'! O I'm E-1,1411
ifycs,uhaltype?
•'*1UUPORTANTeie CLIE+VTSAfUSTCOAJPLfiTL• TIIC 11EQUIItG1) PMOlUtTl' INFOItAIATION ItkQUI•:111-3)
BELOW. Elthera PIAT or SITE HL,\N AIUSTQL• SWIA11TTCD by the a icnt villI THIS AIIIIIACATION.
1'ruperlgDuncnsiolu: IZS 4 y7.0 11246 WRITCU11MC.1TONS (fruits Alvtk.rillc)toPIL(WfAll':
Tax office PIN: ,2 -- __ nn�/
rroperlyAddress: RoadNatnc I610I ��iT-6bagt Dr� " �?F rlti Ff►Inor�d.Jo�C_6v\(L
Cityalp W(,(lJyl (U1. iLcp�,c,1S.l�
If in a Subdivision provide infuriation, as follows: —
Name: E}C Yi'j�LK
Section: Block: Lot: 16 Date hoose cornet slagged:
Tnls is to certify that the infornialion provided is correct to the hest of my knowledge. I uodcrstaud that guy periiiii(s)
issued hereafter are subject to suspension or revocation, if the site plans or intended use change, or if Ilse information
submitted in this application is falsified or changed. 1, also, anderstand 1A411 uat respoariLfcjer all chuges iaranrd f,•oat
Nris application. I, hereby, give clement to the Authorized Represcutalive of 111e Davie Countyy Ilcallh Depar(lutul
to enter upon aborc described prolicrty loci led in Davie County and omied by
In conduct all testing procedures is nectssary to determine the site suitability.
DATE -11-0 3 SIGMA rUltc a s Q(YN�,LA&�f�b & u �
THIS AREA MAY HE USED FOR DRAWING YOUR SITE PLAN (Include all of the follotviug: Existing :old proposed
property lines and dimensions, structures, sethtt" and septic locations).
Site Revisit Charge
Dalc(s):
Client Notification Date:
EHS:
Sign given Account No.
Revised DCHD (05103 Invoice No.
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