332 Cherry Hill Rd (2) OPERATION PERMIT or Ice se only
Davie County Health Department *CDP File Number 193722- 1
�•.�*� 210 Hospital Street 1-6-000-00-018P.O. Box 848 County ID Number:
Mocksville NC 27028 Evaluated For: EXPANSION
Phone: 336-753-6780 Fax: 336-753-1680 Township:
Applicant: Joseph AshburnProperty Owner: Joseph Ashburn
Address: 601 Gladstone Rd Address: 601 Gladstone Rd
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)284-4434 Phone#. (336)284-4434
Propeft Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
332 Cherry Hill Rd
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 S. left on Cherry Hill Rd
#of Bedrooms: 5
#of People:
*Water Supply: PUBLIC
*IP Issued by: 2140-Nations,Robert *System Classification/Description:
TYPE II B.CONY.SYSTEM WITH 750 LINEAR FEET OF
*CA ISSUed by: 2140-Nations,Robert
Saprolite System? O Yes (9 No
Design Flow: 6 0 0 *Distribution Type: GRAVITY-PARALLEL(aq.d-box) Pum
Required?
Q Yes No
Soil Application Rate: 0 a 7 5 *Pre-Treatment:
Drain field
(Nitrification
d 1 6 5 6 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD
7 Installer: Johnny Willard
ngth: 5 5 a ft• Certification#: 1825
Trench Spacing: ()Inches O.C.
P g — 1 ®Feet O.C. EHS: 2399-Steelman,Tiffany
Trench Width: — 3 ()Inches
®Feet Date: 0 1 / 1 a / a 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover: a 4Inches InchesApproval Status
proved
Maximum Trench Depth: 3 6 FXApprovedEl Disap
Maximum Soil Cover: a 4
Inches
Page 1 of 4
CDP File Number 193722 - 1 Septic Tank County ID Number: 1-6-000-00-01a
Manufacturer: shoat Lat.
STB: 964 Long: '
Gallons:
1500 Installer: Johnny Willard
Date: 1 1 / 1 5 / 0 1 5 Certification#: 1825
*EHS: 2399-Steelman,Tiffany
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
ST Marker: ❑ Yes ® No Date: 0 1 / 1 2 / 2 0 1 6
Reinforced Tank: ElYes ® No Approval Status
1 Piece Tank: El Yes ® No ®' Approved❑"+Disapproved '
Pump Tank
Manufacturer: Installer:
PT: Certification#:
Gallons: *EHS:
Date: / / Date:
Riser Sealed ❑ Yes ❑ No
Riser Height: ❑ Yes ❑ No (Min. 6 in.)
Approval' tatus
Reinforced Tank: Y7es 1:1No p "Approved ElDisapproved ,=
1 Piece Tank: ❑ Yes ❑ No
Supply Line
Pipe Size: inch diameter Installer:
Pipe Length: feet Certification#:
*Schedule: *EHS:
Pressure Rated ❑ Yes ❑ No Date:
Approved fittings ❑ Yes ❑ No Approval Status
❑ Approved ❑ Disapproved -
Pump Requarement
CDos.i,ng
Type: Installer:
lume: - Gal Certification#:
rawDown: Inches *EHS:
*Chain:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ NO
Check-valve ❑ Yes ❑ NO Approval Status
PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved
Vent Hole ❑ Yes ❑ No
Anti sip Hole ❑ Yes ❑ No
Page 2 of 4
CDP File Number 193722 - 1 County ID Number: L6-000-00-018
Electric E ui ment
NEMA 4X Box or Equivalent ❑ Yes ❑ NO Installer:
Box 12 inches Above Grade ❑ Yes ❑ NO
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ NO *EHS:
Pump Manually Operable ❑ Yes ❑ NO
*Activation Method: Date:
Approval Status
Alarm Audible El Yes ❑ No -
!'"di
❑ Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2399-Steelman,Tiffany
*Operation Permit completed by:
Authorized State Agen Date of Issue:_ 0 1 / 1 a / 2 0 1 6
yy
Owner/Applicant Signature:
This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seg., and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE 11 B. sewage septic system.
Rule.1961 requires that a Type TYPE 11 B. septic system meet the following criteria:
Minimum System Review By The Local Health Department: N/A
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
N/A
Reporting Frequency By Certified Operator: N/A
Rule.1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract
with a public management entity with a certified operator or a private certified operator for the life of the septic system.
Rule.1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2) (e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements for maintenance and
operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
®Hand Drawing O Import Drawing ;
**Site Plan/Drawing attached.**
Page 3 of 4
OPERATION PERMIT
Davie County Health Department CDP File Number. 193722 - 1
210 Hospital Street County File Number: L6-000-00-018
P.O.Box 848
Mocksville NC 27028 Date:
0 Inch
Drawing Drawing Type: Operation Permit Scale: 00 Mock
A)
-A-
01
..........................
-cp-171
lk—
Page 4 of 4 Pi P2 P3
36
Tax Map:
Address: ? �'r_�tr � F''V
coo Installer: r7-�//)/1p'� , l A-c
-4 D U B EHS:
Date: c?l 1(0
.- ()(14L , 0t N �of Operation Permit Inspection Checklist C)
Location and Separation
1. Distance from septic tank/pump tank to foundationibasement feet
2. Distance from system to well if applicable feet
3. Any other setback(.1950)requirements
Supply line
1. Material supply line is constructed of diameter inches
2. Length of supply line(2'min.)
3. Amount of fall in supply line(1/8"per foot min)
4. Distance from ST/PT to the nitrification field/dist.device) feet
Septic Tank/Pump Tank
1. Visually inspect top of tanks(s),interior&exterior walls,baffle wall and bottom
2. Any honeycombing or exposed rebar present? Circle: YES or NO
3. Visually inspect sanitary tee,lids,and air vent for proper installation and sealant
4. Tank Serial Numbers: STB PT
5. ST Win 6"finished grade?Circle: YEor NO
6. Date of manufacture: ST 1 I-I PT
7. Liquid capacity of tanks Ste_ ►S h U PT
8. Effluent filter type
9. Pipe penetration seal present?Circle: YES or NO
10. Riser(s)present?Circle: YES or No Riser Type
11. Pump Tank riser 6"above finished grade?Circle: YES or NO
12. Riser approved?Circle: YES or NO
Nitrification Field
1. Septic Tank outlet elevation
2. Trench Depth Readings(inches)
3. Number of Trenches Distance between trenches
4. Trench Width
5. Aggregate material type and size 3 4 5 6 57 (Circle)
6. Aggregate Depth(inches)
7. Nitrification lines installed on contour?Circle: YES or NO
8. Innovative system type Installer certified for installation?Circle: YES or NO
9. 2'earthen dam between ST(or d-box)and beginning of nitrification line?Circle:YES or NO
10. Stepdowns
a. 2'undisturbed earthen dam(s) Circle: YES or NO
b. Proper rise over stepdowns?Circle: YES or NO
c. Solid pipe used? Solid,Corrugated or other?
d. Elevation of each stepdown
e. Are all stepdowns lower than the ST outlet elevations? Circle: YES or NO
Distribution Devices
1. Type Is the device watertight? Is it level?
2. Distance from Dist.device to trenches feet
3. Record elevations:Inlets Outlets
C9,
a �
CONSTRUCTION. For office Use Only
AUTHORIZATION *CDP File Number 193722-1
Davie County Health Department County ID Number.
Ls-000•oo-ops
210 Hospital Street Evaluated For. EXPANSION
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 1 1 / 0 5 / a 0 a 0
Applicant: Joseph Ashburn
r
erty Owner. Joseph Ashburn
Address: 601 Gladstone Rd ress: 601 Gladstone Rd
Cly: Mocksville Cly: Mocksville
StatefZip: NC 27028 StatefZip: NC 27028
Phone#: (336)284-4434 Phone#: (336)2844434
Property Location & Site Information
rAddress/Road#: Subdivision: Phase: Lot:
ry Hill Rd
e NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 S. left on Chert'Hill Rd
#of Bedrooms: 5
#of People:
"Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
CClassircation: Provisionally Suitable Inches
Minimum Soil Cover. 1 '2 OYes ®No Inches
6 0 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 _ a 7 5 Maximum Soil Cover: a 4 Inches
'System Class ification/Description: *Distribution Type: GRAVITY-SERIN.
TYPE II B.CONY.SYSTEM WITH 750 LINEAR FEET OF Septic Tank:
NITRIFICATION LINE OR LESS 1 5 0 0 _ Gallons
*Proposed System: 25%REDUCTION 1-Piece: OYes (j)No
Pump Required: OYes ®No OMay Be Required
Nitrification Field a 1 8 a
Sq.ft. Pump Tank: Gallons
No.Drain Lines 6 1-Piece:Oyes ONo
Total Trench Length: 5 4 5 �_ GPM vs— ft. TDH
Trench Spacing: g Inches O.C. Dosing Volume: _ Gallons
_
@Feet O.C.
Trench Width: _ 3 s Olnches
Feet Grease Trap: Gallons
Aggregate Depth:
inches ProTreatment: ONSF OTS-1 :OTS-11
Septic Tank InstallerGrade Level Required:'OI 011 0111 O1V`
Donn 4 of Z
CDP File Number 193722 - 1 County ID Number. L6-000-x0-018
❑ Open Pump System Sheet
Repair System_Required:@Yes ONO ONO, but has Available Space
rDesign
System Trench Spacing: 9 Inches 0. .
ification: Provisionally suitable — Feet O.C.
Trench Width: Inches
w: 6 — 3 . Feet
SoilAggregate Depth:
Applicatan Rate: 0 - a 5 inches
.� Minimum Trench Depth: a 4 Inches
*System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS] Minimum Soil Cover. 1 a Inches'
'Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Maximum Soil Cover, a 4
Nitrification Field a 4 0 Inches
Sq.ft.
No. Drain Lines 6 *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
Total Trench Length: 6 0 0 ftPump Required: Oyes @N_o OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-11
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repairwithout approval of Health Department.
Permit was changed due to not being able to meet fall to the curent system that was to be expanded from a 3 bedroom system to a 5.
"Permit Conditions
The issuance of this permit by the Health Department in noway guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization forwastewater System Constriction shall be valid fora person equal to the period of validity of the improvement Permi%not
to exceed five years,and may be issued at the sametime the Improvement Permit issued(NCGS 130A-336(b)).If the installation has not been
completed during the period of validity of the Construction Permit,the information submitted in the application for a permit or construction
Authorization Is found to have been incorrect,falsified or changed,or the site is altered,the permit orConstruction Authorization shall become
Invalid,and may besuspended or revoked(.1937(g)).,The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,repotting and repair
(1938(b)).
Applicant/Legal Reps. Signature Required? OYeS ONO
Applicant/Legal Reps. Signature: Date:. /
*Issued By: 2140-Nations,Robert Date of Issue: .1,1, / 0 5 / a 0 1 5
Authorized State ent. Malfunction Log QYes t .;
A�-
@Hand Drawing Oimport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 193722 - 1
Davie County Health Department CDP File Number:
210 Hospital Street 1.6-000-00-018
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 1 1 / 0 5 / a 0 1 5
Olnch
Drawing Drawing Type: Constructio uthorization Scale: , OON/A k ft.
WIZ
t d
I
o
r
i'
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital street CDP File Number: 193722 - 1
P.O.Box 848 1.6-000.00-018
Mocksville NC 27028
County File Number.
Date: .1 1 / 0 5 / 2 0 1 5
Click below to import an image from an external location: Drawing Type:Construction Authorization
CONSTRUCTION For office use oniy
AUTHORIZATION *CDP File Number 193722-1
Go.—
Davie County Health Department County ID Number:1-6-000-00-0118
210 Hospital Street Evaluated For- EXPANSION 4�( P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 5 / 0 7 a 0 a 0
Applicant: Joseph Ashburn Property Owner. Joseph Ashburn
Address: 601 Gladstone Rd Address: 601 Gladstone Rd
Cay: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)284-4434 Phone#: (336)284-4434
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
3$2 Cherry Hill Rd
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY Hwy 601 S. left on Cherry Hill Rd
#of Bedrooms: 5
#of People:
'VNater Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
rDesign
ssification: Provisionally suitable Inches
System? Minimum Soil Cover.
y OYes ®No 1 a Inches
low: 6 0 0 Maximum Trench Depth: 3 6 Inches
._.__.
Soil Application Rate: 0 , a 5 Maximum Soil Cover: a 4 Inches
"System Classification/Description: 'Distribution Type: GRAVITY-PARALLEL(eq.d-box)
TYPEUI A.CONV SYSTEM>480 GPD(EXCLUDING SFD)
_ Septic Tank:
1 0 0 0 Gallons
'Proposed System: 250/6 REDUCTION . 1-Piece:. OYes OQ No
Pump Required: OYes ®No OMay Be Required
Nitrification Field 9 6 0 Sq ft Pump Tank: Gallons
No. Drain Lines 3 1-Piece:OYes ONo
Total Trench Length: a 4 0 ft GPM vs— ft. TDH
Trench Spacing: Inches O.C.
@Feet— 9 O.C. Dosing Volume: _ Gallons
Trench Width: Inches
3 2Feet Grease Trio Gallons
P
Aggregate Depth: inches
Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 0111 OIV
Pana i ^f'A
t _ J
L6-000-00-01 S - 1
CDP File Number 193722 - 1 County ID Number. �.
l
s ❑ Open Pump Systemtheet
Repair System Required:@Yes ONo ONo,but has Available Space '
rDnesign
System Trench Spacing: QInches 0.
Classification: Provisionally Suitable — 9 V Feet O.C.
Trench Width: Q Inches
w: 6 B 0 _ 3 a� Feet
Aggregate Depth:
Soil
Application Rate: 0 - a 5 inches
.� Minimum Trench Depth: a 4 Inches
"System Classification/Description:
TYPE III A.CONV SYSTEM>480 GPD(EXCLUDING SFD) Minimum Soil Cover. ;1 a Inches
Maximum Trench Depth: 3 6 Inches
'Proposed System: 25%REDUCTION
Maximum Soil Cover:
Nitrification Fielda` 4 D 0 a _ 4Inches
_
Sq.ft.
N o Drain Lines "Distribution Type: GRAVITY-PARALLEL(eq.d-box)
6
Total Trench Length: 6 0 0 Pump Required: OYes �r@No OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-11
"Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
This Authorization for Wastewater system Constr*on shall bevatld for a person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be issued atthe sametime the Improvement Permit Issued(NCGS 130A-336(b)�If the Installation has not been
completed during the period of validity of the Construction Permit,the information submitted In theapplication for a permit or Construction >.
Authorization Is found to have been Incorrect falsified or changed,or the site Is altered,the permit or Construction Authorization shall became
Invalid,and may be suspended or revoked(.1937(8)).The person owning or controlling the system shall be responsible forassuring compliance
with the laws,rules,and permit conditions regarding system location.Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/Legal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps.Signature: Date:
*Issued By: 2140-Nations,Robert Date of Issue: . 0 5 / 0 8 / .1 0 1 5
---
Authorized State Agents ____ Malfunction Log Oyes
@ Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 193722- 1
210 Hospital Street L"O-0-00-018
P.O. Box 848 County File Number:
Mocksville NC 27028 Date: 0 5 / 0 8 /• 2 0 15
OInch
Drawing Drawing Type:,Construction Authorization Scale: . OBiock = ft,
O N/A
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CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number: 1937221
P.O.Box 848 1-6-000-00-018
Mocksviile NC 27028 County File Number:
Date: .s .5 / 08 / 2015
Click below to import an Image from an external location: Drawing Type:Construction Authorization
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http://maps2.roktech.net/davie_gomaps/index.html 5/8/2015
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
• Davie County Environmental Health
t}� d P.O.Box 848/210 Hospital Street
(+ j;�!!�� Mocksville,NC 27028
0 (336)753-6780/Fax(336)753-1680
?/�� ion For: rte Exxaluation/lmprovement Permit ❑Authorization To Construct(ATC) ❑Both
Type of Application: ZoKew System ❑Repair to Existing System Pexpansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION f ��11
Name to be Billed e % Contact Person ` ya
Billing Address 1 .Qty Home Phone 33C, 309q 41f 3W
City/State/ZIP lll"!f 1.fh 04z_. 9L Business Phone
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Come la ed
NOTE: A survey plat or site plan must accompany this application. Included:❑Site Plan o scale
(Permit is v io for§0 mojpAs th site pl no pi 'on with complete plat.)
Owner's Name 1,f&9 4 Phone Number
Owner's Address City/State/Zip
Property Addres / / City
Lot Size 9 1.C' ITax PIN#
Subdivision Name(if applicable) Section/Lot#
Directions To Site: bo( -5 V ¢o Gl.U�(,<:!l IQd fW y,55 i S 332,
If the answer to any of the following questions is`yes",supporting docume��talion must be attached.
Are there any existing wastewater systems on the site? l9 .❑No
Does the site contain jurisdictional wetlands? ❑Yes[]No
Are there any easements or right-of-ways on the site? ❑Yes❑ o
Is the site subject to approval by another public agency? ❑Yes
Will wastewater other than domestic sewage be generated? ❑Yes go
IF RESIDENCE FILL OUT THE BOX BELOW
#People 2r #Bedrooms 5' #Bathrooms 3 4— Garden Tub/Whirlpool eTes ❑No
Basement: ❑Yes ONo Basement Plumbing: ❑Yes ❑No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building #People
#Sinks #Commodes #Showers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facility water`Wrtsumption)
FOODSERVICE ONLY: Seats
Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Typek-010"inty/City Water O New Well ❑Existing Well ❑Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?❑Yes U<O
If yes,what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use
changes,or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and
locating and flagging or staking facility location,proposed well location and the location of any other amenities.
Prop e is or owner's ega onL trxx,.s-ignature Site Revisit Charge
Date(s):
oZ o�0/S Client Notification Date:
Date EHS:
Sign given ❑Yes❑No Account#
Revised 11/06 Invoice#
Appraisal Card Page 1 of 1
DAVIE COUNTY NC 4/28/2015 7:16:37 AM
LLER LINDA T ETAL Return/Appeal Notes: Parcel:L6-000-00-018
32 CHERRY HILL RD PLAT:11/153 UNIQ ID 22133
301020 ID NO:5756417766
COUNTY TAX(100),FIRE TAX(100) CARD NO.1 of 1 `p
val Year:2013 Tax Year:2015 29.580 AC TRCTI(21.65AC) 21.650 AC 21.650 AC SRC-Inspection e
raised by 17 on 01/01/2014 05003 CHERRYHILL TW-05 Cl- FR-10 EX- AT- LAST ACTION 20140815
NSTRUCTION DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE m
r
.TAL POINT VALUE Eff. BASE m
BUILDING USE MOD Area UAL RATE RCN EYB AYB REDENCE TO ,W
ADJUSTMENTS 97 00 %GOOD EPR.BUILDING VALUE-CARD
TOTAL ADJUSTMENT EPR.OB/XF VALUE-GRD Z
ACTOR TYPE:Vacant p
RKET LAND VALUE-CARD 140,73 >}
TOTAL QUALITY INDEX STYLE: OTAL MARKET VALUE-CARD 140,73
-1
71 PR.
APPRAISED VALUE-CARD 140,73 m
-i
TOTAL APPRAISED VALUE-PARCEL 140,73(
TOTAL PRESENT USE VALUE-PARCEL
TOTAL VALUE DEFERRED-PARCEL
TOTAL TAXABLE VALUE-PARCEL 140,73(
PRIOR
BUILDING VALUE 59,81
BXF VALUE 2,02
ND VALUE 181,32
RESENT USE VALUE
EFERRED VALUE
TAL VALUE 243,150
PERMIT
CODE I DATE NOTE I NUMBER AMOUNT
OUT:WTRSHD:
SALES DATA
[ECORD
ATEDEED INDICATE SALES
K AGE TYPE PRICE
E 422 4 O1 DC E 1E 268 10 00WL E I4 136 11 01 WD E V5 881 5 00 WD G 1 0 9
HEATED AREA d
NOTES A
FLIT 2013
SUBAREA UNIT ORIG% SIZE ANN DEP % 08/XF DEPR
GS RPL OD UA ESCRIPTIO U H N PRICE GOND LDG FACT EY RATE V GOND VALU o
TYPE AREA CS TOTAL OB XF VALUE o
REPLACE o
BAREA o
TAILS a
WILDING DIMENSIONS
ND INFORMATION
IGHEST THER ADJUSTMENTS LAND TOTAL
D BEST USE LOCAL FRON DEPTH/ LND COND ANDMOTES ROAD UNIT LAND UNT TOTAL ADJUSTED LAND OVERRIDE LAND
SE CODE ZONING TAGE EPT SIZE MOD FACT RF AC LC TO OT TYPE PRICE UNITS TYP ADJST UNIT PRICE VALUE VALUE NOTES
URAL AC 0120 258 0 1 1.0000 4 11.0000[05+20+00-10-05 PW 6,500.0 21.650 AC 1.00 6,500.00 140725 OSHAPE
OTAL MARKET LAND DATA 21.65 140 73
TAL PRESENT USE DATA
http://66.226.39.229//ITSNet/AppraisalCard.aspx?parcel=L600000018 4/28/2015
{
DAVIE COUNTY HEALTH DE AR NT
Environmental Health Section
Soil/Site Evaluation
I APPLICANT INFORMATION PAOPERTY INFORMATION
i
-3 YP Aft
I I o7
!
. I
Water Supply: On- ite Well Community Public
I
Evaluation By: Augr Boring Pit Cut
FACTORS j 1 4 5 6 7
Landscape position ( j
Slope% 2
HORIZON I DEPTH o n-�
Texture group f)CG- Gj
Consistence j
Structure j
Mineralogy S —
HORIZON II DEPTH — !
! Texture group , j !
Consistence ( f'
j Structure
Mineralogy
HORIZON III DEPTH ►. ! !
Texture group
Consistence
s I
Structure
Mineralogy ( I
HORIZON IV DEPTH { I
Texture groupj
Consistence ( j
Structure �.
Mineralogy
SOIL WETNESS I I
RESTRICTIVE HORIZON C ( I
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE '0-)0A;1 0-a d I
SITE CLASSIFICATION: Pte- I EVALUATI I N BY
6, ��
LONG-TERM ACCEPTANC)1RATE: i IOTHER(S)I�RESENT:; ,
1 ,
REMARKS: i
LEGEND }
Landscape Position j
R-Ridge S -Shoulder' ' L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV- onvex slope T-Terrace FP--Flood plain H L Head slope
Texture
S -Sand LS-Loamy san SL-Sandy loam L-Loam SI,Silt
SICL Silty clay loam SII;-Silty loam CL-Clay loam SCL-dandy clay loam ;
SC-Sandy clay SIC-Sil clay C-Clay `
Ty hhl I I
VFR-Very friable FR-F 'able F1-Firm VFI Very firm IEFI-Extre lely firm
NS-Non sticky SS-.Slightly sticky S -Sticky VS -Very Stich
NP-Non plastic SP-Slig tly plastic P-Plastic VP-Very plastic
Structure
SC-Single grain M-M 'sive CR-Crumb GR-Granular ABK-Angular blocky.
SBK-Subangular blocky L-Platy PR-Prismatic
{
Mineralogy `I
1:1,2:1,Mixed i
otes I
i Horizon depth-In inches
Depth of fill-In inches i
Restrictive horizon-Thickness and inches from land surface i
Saprolite-S(suitable),U(unsu�table)• I
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(U rovisionally suitable),U(unsuitable) {
T TAn T -- - I-o•_ __�i�-__�cn - I
Davie County Health Department
18 Environmental Health Section ,
r; P.O.Box 848
210 Hospital Street
Courier#: 09-40-06 1911
Mocksville,NC 27028
Phone:(336)-753-6780 Fax:(336)-753-1680
ON-SITE WASTEWATER CERTIFICATION
(Che c One) Replacement Remodeling Reconnection
Name: V(J �S0)2 �r��t '- Phone Number (Home)
Mailing Address: (Work)
Email Address:
Detailed Directions To Site:
1
Property Address:
Please Fill In The Following Information Abo t The EXISTING Facility: iA /
Name System Installed Under: A/WType Of Facility: �-
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 No If Yes,Explain:
Please FillIn Th llowformation About The NEW Facility:
Type Of Facility: *WAZNumber Of Bedrooms: Number of P ople
Pool Size: Garage Size: 3 Other: 12 � � 01
Requested By: . Date Requested:
(Sign �-
ti
For Environmental Health Office Use_Only
Approved Disapproved
omments:
Environmental Health Specialist Date:
*The signing of this form by the 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#: