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168 Hickory Tree Road Lot 14 (2)t Davie County, NC Tax Parcel Report Wednesday, January 11, 2017 WARM -N T: THl, IS INUT A SURVEY Parcel Information Parcel Number: J7010A0014 Township: Fulton NCPIN Number: 5768233090 Municipality: Account Number: 8300392 Census Tract: 37059-804 Listed Owner 1: CARTER ANDREW ROSS Voting Precinct: FULTON Mailing Address 1: 168 HICKORY TREE ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-20 State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag. District: No Legal Description: LOT 14 HICKORY TREE SECTION ONE Fire Response District: FORK Assessed Acreage: 0.45 Elementary School Zone: CORNATZER Deed Date: 6/2011 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 008610057 Soil Types: Gn132 Plat Book: 0004 Flood Zone: Plat Page: 170 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding & Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: 161 All data Is provided as is without warranty or guarantee of any Idnd 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 Countys GIS websRe 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 NCor arising out of the use or Inability to use the GIS data provided by this website. - i . .:�: :.Z.. 'S r-s:,;c�J+L'd � +i�x'.•i- K.p �'+.w -.4 u„� a .-sr � .. � � .. .. -'�. +. - ,� .. ... DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION �-•MOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c ;. Sewage Treatment ar d Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name ?y, 1, i�;y�f-YOIKV�aj�if�r/�'�,.?i'I Serri Date ,l/.N2 5436 Location /r' Subdivision Name-!`��1�"�/ ���'� Lot No. ` Sec. or Block No. -- Lot Size House House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES p NO Gam' Specifications for System: Auto Dish Washer YESNO p 1 Auto Wash Machine YES [tj NO C] Type Water Supply el' *This permit Void if sewage system described below is not installed within 36 months from date of issue. r w,y Improvements permit by *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 day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: Sys em Installed by Certificate of Completion � �� Date *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in -NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. . - �3� 3rd � � - . , � • V APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT�9 Davie County Health Department DEQ Q Z Environmental Health Section Q \v P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit Requested" 2. Address n) 3. Property Address Home Phone 6 3`/ -Z-y2, Business Phone 63y 353 ' 4. Permit To: a) Install Alter Repair b) Privy Conventional__/ Other Type Ground Absorption c) Sub-Division.//k,(;_,, i a Sec. 1157- Lot No. �• �� 5. System used to serve what type facility: House K Mobile Home Business Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions - 00 /` Bed Rooms. 9 Bafh RoomsJ2-, De w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures: commodes .Z- urinals garbage disposal lavatory ,?, showers 2 washing machine dishwasher / sinks 8. a) Type water supply: Publics C Private Community b) Has the water supply system been approved? Yes ✓ No 9. a) Property Dimensions fo o X 05700 b) Land area designated to building site - c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is cor ect to the best of my knowledge. Zl"l Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: /L/, e h- ( C) /))P,r, p e- r 17 rr e_' 0a Gaijs/c+-7 DCHD (6-82) 0" 0/' / V aree-,Z 21" iia../ p /fey 7()/ ©n d,e) �vl DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED -Tree- (office use only) yes rlh'O;'-) 7---� 1. 1 am the owner of the above described property. yes no 2. 1 am not the owner of the above de70y ribed property, however, I certify that I have consent from crry , owner to obtain a % owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes' no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. - 31- � rL DATE /SIGNATURE/ 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: Owner only Owners designated representative Anyone requesting results Only those listed below DATE S GI TURE DCHD (11 /84) STATEMENT f DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION 210 HOSPITAL STREET P. 0. BOX 665 MOCKSVILLE, NORTH CAROLINA 27028 (704) 634-5985 DATE 02-14-89 Howard Realty 330 S. Salisbury St. Mocksville, NC 27028 Attn: Diane Foster I Site Eval. & Permit 5436/Snipes, David(Hickory� L T�ePIL �Sec. 2 -Lot 13 - $50.00 � DETACH D WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIP T. 02-14-89 Site Eval. & Permit 5436/Howard Realty $50.00 Hickory Tree/Sec. 2 -Lot 13(Snipes, David) �a9 BALANCE DUE — $50.00 • Davie County Nealtk Department and .tome Nealll Ayency 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE. N.C. 27028 PHONE: (704) 834-5985 February 22, 1990 David Snipes P. 0. Box 344 Cooleemee, NC 27014 Re: Sewage System Installation Hickory Tree - Lot 13 Dear Mr. Snipes: The septic tank system that serves this residence was designed, inspected and approved by this office on January 18, 1990. With proper maintenance and use it should function properly. Sincerely, &Oyj'e��� JOS07 Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued- in Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name � /i Date _ %`: •s._4.+ f� Location Subdivision Name Lot No. !�_ Sec. or Block No. Lot Size House Mobile Home _ Business Speculation -� No. Bedrooms �-� No. Baths �~ No. in Family _ Garbage Disposal YES ❑ NO p-' Specifications for System: Auto Dish Washer YES m NO ❑' Auto Wash Machine YES b NO ❑ �f t Type Water Supply �� _ '�1%� �. i�/-.� ; ✓% :,'i' -1= *This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by *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 day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: istalled by � M f -S Certificate of Completionf� Date Z *The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. . I. STATEMENT ,, DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION 210 HOSPITAL STREET P. 0. BOX 665 MOCKSVILLE, NORTH CAROLINA 27028 (704) 634-5985 �( DATE /v " z / - U F C"©&fN A 5�- . E kb� Fs -I L I DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT. OPERATION PERMIT ,.. Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Hope Homes of Davie County Address: 321 Redland Road City: Advance State/Zip: NC 27006 Phone #: (336) 909-2910 "CDP File Number 228407-1 5768235000 County ID Number. Evaluated For, NEW Township: (Property owner. Hope Homes of Davie County Address: 321 Redland Road Cly: Advance State/Zip: NC 27006 `Phone #: (336) 909-2910 Property Location & Site Information Address/Road #: Subdivision: Hickory Tree Phase: Lot: 15 Hickory Tree Rd Mocksville NC 27028 Directions Structure: SINGLE FAMILY Hwy. 64 East, right on No Creek Rd. On left Hickory Tree Rd # of Bedrooms: 3 # of People: *water Supply: PUBLIC *IP Issued by. 2i4o-Nations, Robert *System Class ification/Description: TYPE 11 A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140 -Nations, Robert Sapr olite System? OYes ,0No Design Flow: 3 6 0 Distribution Type: GRAVITY -SERIAL Pump Required? O Yes G No Soil Application Rate: 0 3 *Pre Treatment: Drain field cation Field r 1 a 0 0 Sq• It• *System Type: INFILTRATOR QUICK 4 STANDARD Drain Lines 5 Installer: Randy Miner Total Trench Length: 3 0 0 Certification #: 1128 Trench Spacing: _ 9 Inches O.C. Feet O.C. *EH S: 2140 - Nations. Robert Trench Width: _ 3 Olnches Feet 0 9/ 0 9/ 2 0 1 6 Date: Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Inches -Approval Status' Maximum Trench Depth: 3 6 ®, Approved 0 Disapproved Inches Maximum Soil Cover: 2 4 Inches CDP File Number 228407 - 1 C� Manufacturer. Shoat STB: 760 Gallons: 1000 — Date: 0 6/ 1 4/.2 0 1 6 'Filter Brand: POLYLOK PL -122 With Pipe Adapter ST Marker. ❑ Yes ® No nforced Tank: ❑ Yes R No 1 Piece Tank: ❑ Yes F No ol- Manufacturer. County ID Number: 5768235000 otic Tank Lat. Long: Installer: Randy Miller Certification #: 1128 *EH S: 2140. Nations, Robert Date: 0 9/ 0 9/ 2 0 1 6 Pump Tank PT: Gallons: Dosing Volume: — Date: Gal Certification #: Draw Down: RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6 in.) Reinforced Tank: ❑Yes ❑ No 1 Piece Tank: ❑Yes Valves Accessible ❑ No / Poe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ No Approved fittings ❑ Yes ❑ No Installer Certification #: *EH S: Date: Supply Line Installer. Certification #: *EH S: Date: / Pump Type: / Installer. Dosing Volume: — Gal Certification #: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ No Check -valve ❑ Yes ❑ No ApprovatStatus� PVC unions ❑Yes ❑ No❑ Approvetl ❑ Disapproved Vent Hole ❑ Yes ❑ No \ Anti -siphon Hole ❑ Yes ❑ No 's 1 CDP File Number 228407-1 N EMA 4X Box or Equivalent ❑ Yes Box 12 inches Above Grade ❑ Yes Sox Adj. To Pump Tank ❑ Yes Conduit Sealed ❑ Yes Pump Manually Operable ❑ Yes *Activation Method: County ID Number: 5768235000 Electric EaulDment ❑ Alarm Audible ❑ Yes ❑ No Alarm Visible ❑ Yes ❑ No 2140 • Nations, Robert *Operation Permit completed by: 3 Authorized State Owner/Applicant Signature: Approvat !81- us? Approved C lsapproved Date of Issue: 0 9/ 0 g/ a 0 1 6 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. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE u A sewage septic system. Rule .1961 requires that a Type TYPE 11 A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NJA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: NIA Reporting Frequency By Certified Operator: N/A Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora homelbusiness owner must maintain a valid contract with a public management entitywith 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 formaintenance 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 Olmport Drawing **Site Plan/Drawing attached.** No Installer. ❑ No Certification #: ❑ No ❑ No *EH S: ❑ No Date: Alarm Audible ❑ Yes ❑ No Alarm Visible ❑ Yes ❑ No 2140 • Nations, Robert *Operation Permit completed by: 3 Authorized State Owner/Applicant Signature: Approvat !81- us? Approved C lsapproved Date of Issue: 0 9/ 0 g/ a 0 1 6 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. Seq., and all conditions of the Improvement Permit and Construction Authorization. This property is served by a TYPE u A sewage septic system. Rule .1961 requires that a Type TYPE 11 A. septic system meet the following criteria: Minimum System Review By The Local Health Department: NJA Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: NIA Reporting Frequency By Certified Operator: N/A Rule .1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywith a certified operatoror a private certified operator forthe life of the septic system. Rule .1961 requires that Type VI septic systems designed fora homelbusiness owner must maintain a valid contract with a public management entitywith 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 formaintenance 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 Olmport Drawing **Site Plan/Drawing attached.** OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Operation Permit CDP File Number: 228407' 1 County File Number: 5768235000 Date: O Inch Scale:. OBlock ON/A . ,, I LJ 1 -71-1 i III , i f � f f i ---�-- if h ___1 (771 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Hope Homes of Davie County Address: 321 Redland Road City: Advance State/Zip: NC 27006 Phone #: (336) 909-2910 i For Office Use OnIV *CDP File Number 228407 -1 County ID Number: 5768235000 Evaluated For: NEW Township; PERMIT VALID UNTIL: 0 7/ 1 8 2 0 2 1 Property Owner: Hope Homes of Davie County Address: 321 Redland Road City: Advance State/Zip: NC 27006 Phone #: (336) 909-2910 Property Location & Site Information 4ddress/Road #: Subdivision: Hickory Tree Phase: Lot: 15 Hickory Tree Rd Mocksville INC 27028 Directions . _ . Hwy 64 East, right on No Creek Rd. On left Hickory Tree Structure: � SINGLE FAMILY Rd # of Bedrooms: 3 # of People: *Water Supply: PUBLIC Classification: Provisionally suitable Minimum Trench Depth: 2 4 Inches \Site Minimum Soil Cover: 1 2 Saprolite System? O Yes ._. (9 No Inches Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 3 Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY - SERIAL TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 - Gallons *Proposed System: 25% REDUCTION 1 -Piece: O Yes ® No Pump Required: . O Yes ®No O May Be Required Nitrification Field 1 -2 0 Sq. ft. Pump Tank: Gallons No. Drain Lines 4 1 -Piece: OYes ONo Total Trench Length: 3 0 0 GPM --vs— ft. TDH ft. Trench Spacing:— 9 O ® Inches O.C. Feet O.C. Dosing Volume: — Gallons Trench Width: 3 OInches ® Feet — Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: O NSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: O 1 OII 0111 01V / Page 1 of 3 CDP File Number 228407 - 1 County ID Number: 5768235000 Ir System Required: VY 1r e5 v INO v Igo, UUL Has HyaIIaDie a *Site Classification: Provisionally Suitable Design Flow: Soil Application Rate: 0 3 *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) *Proposed System: 25% REDUCTION Nitrification Field 1 a 0 0 Sq. ft. No. Drain Lines 4 Total Trench Length: 3 0 0 ft, ❑ Open Pump System Sheet Trench Spacing: 90 Inches O. ® Feet O.C. Trench Width: — 3 Inches Feet Aggregate Depth: inches Minimum Trench Depth: a 4 Inches Minimum Soil Cover: 1 a Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: a 4 Inches *Distribution Type: GRAVITY - SERIAL Pump Required: Oyes ®No O May Be Required Pre -Treatment: O NSF OTS -I OTS -II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. cR"=adi=ngs 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Mww d g 2000 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit, not to exceed five years, and may be issued at the same time 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 or Construction Authorization shall become Invalid, and may be suspended or revoked (.1937(8)). 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, reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? O Yes ONO Applicant/Legal Reps. Signature: Date: *Issued By: 2140 - Nations, Robert Date of Issue: 0 7 1 8 .2 0 1 6 Authorized State Agent: Malfunction Log Oyes ® Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 CDP File Number: County File Number: 5768235000 Date: 07/ 18/.1016 O Inch c. n1n. n MI—L, = Page 3 of 3 P1 P2 ft. CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street CDP File Number: P.O. Box 848 5768235000 Mocksville NC 37 d 4 County File Number: ( -- 1 4 —1 QP Date:.0.7. / .1.8. .10 1 6 ......... . Click below to import an im ge from n external location: Drawing Type: Construction Authorization J Page 3of3 P1 P2