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1721 Peoples Creek RdDavie County, NC Tax Parcel Report 4+D i � Wednesday, October 5, 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: WA1tINJINti: "l'ri1J 1N NU1' A lUKV11:Y Middle School Zone: Parcel Information 005890417 G909OA000201 Township: Shady Grove 5789494539 Municipality: 82523850 Census Tract: 37059-804 SHELTON ADAM B Voting Precinct: EAST SHADY GROVE 1721 PEOPLES CREEK ROAD Planning Jurisdiction: Davie County ADVANCE Zoning Class: DAVIE COUNTY R -A NC Zoning Overlay: 27006-7453 Voluntary Ag. District: No 8.990 AC PEOPLES CREEK RD Fire Response District: ADVANCE 8.94 Elementary School Zone: SHADY GROVE Building Value: Land Value: Total Assessed Value: 1/2005 Middle School Zone: WILLIAM ELLIS 005890417 Soil Types: PaD,WeC,WeB,PcB2 Flood Zone: Watershed Overlay: DAVIE COUNTY 175120.00 Outbuilding & Extra 34260.00 Freatures Value: 90040.00 Total Market Value: 299420.00 299420.00 9tt� 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 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 noUpS� NC or arising out of the use or inability to use the GIS data provided by this website. Davie County Health Department 1886 Health Section P.O. Box 848 , 210 Hospital Street , A, , 0 Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WAS CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: ��'" U �/0'i Phone Number -�(Home) Mailing Address: �Z / P ` U(/ — (// (Work) 4�� t 2%0� Email Address: o�'I Qfe 4 "00/ Detailed Directions To Site: Property Please Fill In The Following Information About The EXIST NG Facility: Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): r ,J r Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes • If Yes, For How Long? Any Known Problems? Yes �Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: '110Ad a ��'� Number Of Bedrooms: Number of People Pool Size: Garage Size: Other: ? Requested By: Date Requested:✓� (Signature) For Environmental Health Office Use Only C�,D//��isapproved �%�j Comment,-! S7A,Lw A -i IPA, ' 'T"7 f--�1G_.�]/I Q 1J I 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 # Paid By:_ Account #: Amount:$ Date: Received By:_ Invoice #: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Boa 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Account #: 990002872 Tax PIN/EH #: 5789-49-4539 Billed To: Lori Shelton Subdivision Info: Reference Name: Location/Address: Peoples Creek Rd. -27028 Proposed Facility Residence Property Size: 8.99 acres ATC Number: 4019 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 WASTEWATERCOTR/UCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: /—,'! Date: 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 B : P Y Y Environmental Health Specialist's Signature: Date:l/ DCHD 05/99 (Revised) W Account #: 990002872 Billed To: Lori Shelton Reference Name: Proposed Facility Residence DAVIE COUNTY HEALTH DEPARTMENT I ?� Environmental Health Section P. O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 IMPROVEMENT/OPERATION PERMIT Tax PIN/EH #: 5789-49-4539 Subdivision Info: Location/Address: Peoples Creek Rd. -27028 Property Size: 8.99 acres ATC Number: 4019 **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 1 I 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. -1-- Residential Specification: Building Type /J #People #Bedrooms #Baths 0- Dishwasher: Garbage Disposal: ❑ Washing Machin Basement w/Plumbing: ❑ Basement/No Plumbinge�� Commercial Specification: Facility Type #Pe C3/ople #People/Shift #Seats Industrial Waste: Lot Size Type Water Supply �l Design Wastewater Flow (GPD) Site: New Repair ❑ System Specifications: Tank Size/00 GAL. Pump Tank GAL. Trench Width--l?'/Rock Depth /� Linear Ft.�,?00 Other: Required Site Modifications/Conditions: IMPROVEMENT/OPERATION PERMIT LAY I FINISHED GRADE. ****NOTICE: Contact a p system between 8:30 a.m. to 9:30 a.m. or 1:00 p. . to JS rPROVED EFFLUENT FILTER. RISER(S) IF 6 " BELOW ve of the Davie County Health Department for final inspection of this n. on the day of installation. Telephone # is (336)751-8760.**** Environmental Health Specialist's Signature: Date: DCHD 05/99 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & Davie County Health Department 0 v Environmental Health Section J P.O. Box 848/210 Hospital Street VAR 7 0 2005 Mocksville, NC 27028 (336) 751-8760 �NROP1�nEN ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE My INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 1. Name to be Billed/1U� `u g Contact Person Mailing Address Home Phone 336 '7J'5 6911 City/State/ZIP Business Phone 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: ❑ Site Evaluation fH/Improvement Permit/ATC ❑ Both 4. System to Service: VHouse ❑ Mobile Home ❑ Business ❑ Industry ❑ Other S. Type system requested: (Conventional ❑ conventional modified ❑ innovative 6. If Residence: # People C- # Bedrooms ._ # Bathrooms dishwasher ❑Garbage Disposal lwashing Machine ❑Basement/Plumbing LJBasement/No Plumbing 7. If Business/Industry /Other: verify type # Commodes a_ # Showers a - IF FOODSERVICE: # Seats # Urinals # People # Sinks # Water Coolers Estimated Water Usage (gallons per day) 8. Type of water supply: County/City ❑ Well ❑ Community 9. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes Er"No If yes, what type? ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION. Property Dimensions:��2 C WRITE DIRECTIONS (from Mocksville) to PROPERTY: a Tax Office PIN: # Property Address: Road Name /'ewofea CC@Gn T' City/Zip AdyC..nG� If in a Subdivision provide information, as follows: Name: Section: Block: Lot: Date home corners flagged:0-3 i,D 0�3 This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) 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. I, also, understand that I am responsible for all charges incurred from this application. I, 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 suitability. 01 DATE .3��D OJ SIGNATURE �'d', 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). Sign given �C < Revised DCHD (05/03 Site Revisit Charge Date(s): Client Notification Date: EHS: Account No. Invoice No. 7Q�' Z7 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990003145 Tax PIN/EH #: 5880-40-3420. C Billed To: Kenneth Lapiejko Subdivision Info: Reference Name: Location/Address: 1715 Peoples Creek P >d -270006 Proposed Facility: Residence Property Size: 14 acres Date Evaluated: L �% Water Supply: On -Site Well Community Evaluation By: Auger Boring I. Pit Public l/ FACTORS 1 2 3 4 5 6 7 Landscape position L Sloe % HORIZON I DEPTH = r' - Texture groupLL Consistence Structure Mineralogy HORIZON II DEPTH 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: lD LONG-TERM ACCEPTANCE RATE: 1 REMARKS: EVALUATION BY:��7 OTHER(S) PRESENT: 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 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 05/99 (Revised) Lu z o� W 2 n. _MPORARY INE POSTS NO FENCING LACE) , %TRACT 1 AREA= 5.03 AC. 16" TRE 301. " 14 TRE • 15" OAK 24" OAK 016" OAK 30" OAK 14" OAK 12" OAK 14" HICKOR • 14" OAK 12" OAK 30" POPLAR „ 18" HICKO P OF CREEK BANK (jYPICALi 14 OAK A PROXIMATE TO 20" POPLAR ��. 20" DBL OAK BUILDING LINE PB 6 PG 33 \ S07.00'21 "E (NEW L\ 431.79' cvIRS Y`INLET LOCATION �_S07'0O'21"F Ano o-)• rrnre� r,� NOT DETERMINED 30" POP AR