220 Sanctuary Ln OPERATION PERMIT or ice use URIV
Davie County Health Department *CDP File Number 114240-1
210 Hospital Street H60000 D02003
P.O.Box 848 County ID Number.
Mocksville NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Charles J. and Naomi Hagerman Property Owner. Charles J.and Naomi Hagerman
Address: 245 Sain Road Address: 245 Sain Road
City: Mocksville City: Mocksville
State2ip: NC 27028 State2ip: NC 27028
Phone#: (336)751-1105 Phone#: (336)751-1105
Propertv Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Sanctuary Lane
Mocksville NC 27028 Directions
structure: SINGLE FAMILY 158 right on to Sain Raod, Left ont Milling Left Onto
Sanctuary Lanem go to end of raod Lot 3 on right.
#of Bedrooms: 4
#of People: 3
*Water Supply: EXISTING WELL
*IP Issued by. *System Classification/Description:
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS)
*CA issued by: 2140-Nations,Robert Saprolite System? QYes tNo
Design Flow: 4 8 0 3 * GRAVITY-SERIAL Pump Required?
Distribution Type: QYes (DNo
Soil Application Rate: 0 - a 5 a *Pre Treatment:
Drain field
rNo.
cation Field 1 9 a 0 Sq. 8• *System Type: INFILTRATOR QUICK 4 STANDARD
rain Lines 5 Installer: Donnielakey
Total Trench Length: 6 4 0 8• Certification#: 1108
Trench Spacing: — 9 ()Inches O.C.
Q Feet O.C. *EH S: 2140-Nations.Robert
Trench Width: 3 Inches
- gFeet Date: 0 5 / 1 9 / 2 0 1 4
Aggregate Depth: inches
Minimum Trench Depth: 3 6 Inches
Minimum Soil Cover. a 4Inches Approval Status'
Maximum Trench Depth: 3 6 Inches ®'Approved Disapproved ;=
Maximum Soil Cover: a 4
Inches
CDP File Number 114240 - 1 Septic Tank •County iD Number: H600000a2DO3 .
-
Manufacturershoat Let.
STB: 760 Long: .
Gallons:
1000 Installer: bonny Lakey
Certification#: 1108
Date: 0 1 / a 8 / a 0 1 4
*ENS: 2140-Nations.Robert
*Filter Brand: POLYLOK PL-122 With Pipe Adapter
Date: 0 5 1 9 / 2 0 1 4
ST Marker. El Yes ten. NO -
Reinforced Tank: ❑ Yes M NO Approval Status
Piece Tank: ❑ Yes ® No ® Approved❑ Disapprove ;
Pump Tank
Manufacturer. Installer
PT: Certification#:
Gallons: 'EHS:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ N0 (Min.6 in.) 'AAPcovalStatus
einforced Tank: ❑ Ye s ❑ No CI Approved❑ Disapproved'
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 f
❑ Approved❑ Disapproved
Pump Requirement
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 Appraval`Status°
PVC Unions ❑ Yes El No ❑ Approved O Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole E3 Yes 0 No
CDP File Number 1142401- 1 = County ID Number: H60000002003
Electric Equipment
NEMA 4X Box or Equivalent Q Yes ❑ No Installer:
Box 12 inches Above Grade ❑ Yes ❑ NO
Certification#:
Box Adj. Pump Tank Q Yes ❑ No
Conduit Sealed Q Yes ❑ NO *EHS:
Pump Manually Operable Q Yes ❑ No
*Activation Method: Date:
Alarm Audible ❑ Yes ❑ No Approval Status
;Approved❑ Disapproved
Alarm Visible ❑ Yes ❑ No
2140•Nations.Robert
*Operation Permit completed by: le
Authorized State Agent: Date of Issue: 0 5 / 1 9 / 2 0 1 4
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. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE tl A. sewage septic system.
Rule.1961 requires that a Type TYPE lr A septic system meet the following criteria:
Minimum System Review ByThe Local Health Department: PVA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency ByCertified Operator:
N/A
Reporting Frequency By Certified Operator:NIA
Rule.1961 requires that a Type IV and V septic systems designed fora hometbusiness owner must maintain a valid contract
with a public management entitywth a certified operatoror a private certified operator forthe life of the septic system.
Rule.1961 requires that Type VI septic systems designed fora hometbusiness 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 fora 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 Olmport Drawing
**Site Plan/drawing attached.**
OPERATION PERMIT 114240 = 1
Davie County Health Department CDP File Number:
210 Hospital Street H60000002003
P.O.Box 848 County File Number:
Mocksvilte NC 27028 Date:
O Inch
Dra`vin9 Drawing Type: Operation Permit Scale: ON A k ft.
O
1
111
I
—j——j-
07
II
e 4? =�
--- -------------
{
. V
CONSTRUCtION For Office Use Only
AUTHORIZATION *CDP File Number 114240- 1
Davie County Health Department County ID NumberHs0000002003
t_ 210 Hospital Street Evaluated For. NEW
P.O.Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone:336-753-6780 Fax:336-753-1680 0 4 / 1 5 / a 0 1 9
Applicant: Charles J.and Naomi Hagerman Property Owner. Charles J.and Naomi Hagerman
Address: 245 Sain Road Address: 245 Sain Road
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone#: (336)751-1105 Phone#: (336)751-1105
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Sanctuary Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 158 right on to Sain Raod, Left ont Milling Left Onto
Sanctuary Lanem go to end of raod Lot 3 on right.
#of Bedrooms: 4
#of People: 3
*VNater Supply: ExiSTING wELL
System Specifications
Minimum Trench Depth: a 4
Site Classification: Provisionally Suitable Inches
Saprolite System? OYes X No Minimum Soil Cover. 1 a Inches
Design Flow: 4 8 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-SERIAL
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1 0 0 0 Gallons
*Proposed System: CONVENTIONAL 1-Piece: O Yes ®No
Pump Required: O Yes ®No O May Be Required
Nitrification Field 1 9 a 0_ Sq.ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: OYes ONo
Total Trench Length: 6 4 0 ft, GPM—vs— ft. TDH
Trench Spacing: Inches O.C.
9 Feet O.C. Dosing Volume: Gallons
Trench Width: 3 Inches
Feet Grease Trap: Gallons
Aggregate Depth: 1 a
inches Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01 O II 0111 01V
Page 1 of 3
CDP,FilNumber 114240 - 1' r.County ID Number H60000002003
ts
❑ Open Pump System Sheet
Repair System Required:OYes O No O No, but has Available Space
Repair System
Trench Spacing: (� Inches O. .
*Site Classification: Provisionally suitable — Feet O.C.
Trench Width: O Inches
Design Flow: 4 8 0 _ 3 ®Feet
Soil Application Rate: 0 - 5 Aggregate Depth: 1 a inches
u
*System Classification/Description: Minimum Trench Depth: a 4 Inches
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover.
LESS) 1 Inches
*Proposed System: CONVENTIONAL Maximum Trench Depth: 3 6 Inches
Maximum Soil Cover. a 4
Nitrification Field 1 9 2 0 Sq.ft.
Inches
No. Drain Lines 4 *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 6 4 0 ft Pump Required: OYes ®No OMay 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. R m
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. R ^9
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 130A336(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(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,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 4 / 1 5 / a 0 1 4
02
Authorized State Agent: Malfunction Log Oyes
Al
(9 Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
y CONSTRUCTION AUTHORIZATION
Davie County Health Dgpartment CDP File Number: 114240 - 1
210 Hospital Street H60000002003
P.O.Box sas County File Number:
Mocksville NC 27028 Date: 04 / 15 /2014
O Inch
Drawing Drawing Type: Construction Authorization Scale: . O Block
O N/A
IT 4
0.
Page 3 of 3
P1 P2
L CONSTRUCTION AUTFJORIZATION
Davie County Health Department
210 Hospital street CDP File Number: 114240 - 1
P.O.Box 848 H60000002003
Mocksville NC 27028 County File Number:
Date: A4,/ 15 / .10 14
Click below to import an image from an external location: Drawing Type:Construction Authorization
Page 3 of 3
P1 P2
J '
'4, ONSTRUCTION . FICDPFileNumber
or Office Use Only
AUTHORIZATION 114240-1
Davie County HealthDepartment umber: H60000002003
f a 210 Hospital Street Evaluated For: NEW
.� ,. P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 4 / 1 5 / .2 0 1 9
Applicant: Charles J.and Naomi Hagerman Property Owner: Charles J.and Naomi Hagerman
Address: 245 Sain Road Address: 245 Sain Road
CRY: Mocksville City: Mocksville
StatefZip: NC 27028 State/Zip: NC 27028
Phone#: (336)751-1105 Phone N: (336)751-1105
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Sanctuary Lane
Mocksville NC 27028 Directions
Structure: SINGLE FAMILY 158 right on to Sain Raod, Left ont Milling Left Onto
#of Bedrooms: 4 Sanctuary Lanem go to end of raod Lot 3 on right.
#of People: 3
`Water Supply: EXISTING WELL
System Specifications
Minimum Trench Depth:
Site Classification: Provisionally a 4 Inches
Saprolde System? OYes QNo Minimum Soil Cover. 1 a Inches
Design Flow: 4 8 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 . a 5 Maximum Soil Cover: a 4 Inches
*System Class ification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
*Proposed System: CONVENTIONAL 1-Piece: OYes QNo
Pump Required: OYes QNo OMay Be Required
Nitrification Field 1 9 a 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: OYes ONo
Total Trench Length: 6 4 0 ft GPM vs— ft. TDH
Trench Spacing: 9 QInches O.C. Rosin Volume: Gallons
Feet O.C. g —
Trench Width:
3 8inches
Feet Grease Trap: Gallons
Aggregate Depth: 1 a inches
Pre Treatment: ONSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: 01 011 0111 01V
Pagel of 3
CDP File Number` 114i40 -1 _ County ID Number: H60000002003
- ❑ Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
rDesign
System
Trench Spacing: Q Inches O. .
ification: Provisionally Suitable – 9 Feet O.C.
Trench Width: 8 Inches
w: 4 – 3 Feet
Soil Application Rate: Aggregate Depth: 1 a
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: CONVENTIONAL Maximum Trench Depth: 3 6 Inches
Nitrification Field 1 9 2 0 Sq.ft. Maximum Soil Cover: a 4 Inches
No. Drain Lines 4 'Distribution Type: GRAVITY-SERIAL
Total Trench Length: 6 4 0 ft Pump Required: OYes ONo OMay Be Required
Pre Treatment: ONSF OTS-1 OTS-II
'Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
7!
'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.
wa
2(
This Authorization for Wastewater System Constriction shall bevalid fora person equal to the period of validity of the improvement Permit,not
to exceed five years,and may be issued at the sane 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 applicauon 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(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rimes,and permit conditions regarding system location,installation,operator,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 4 1 5 .2 0 1 4
Authorized State Agent: Malfunction Log Oyes
GHand Drawing Olmport Drawing
**Site PlanlDrawing attached.**
Page 2 of 3
• CONSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number. 114240 - 1
210 Hospital Street H60000002003
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 04 / 15 / 2 0 1 4
Olnch
Drawing Drawing Type: Construction Authorization Scale: , 013lock
ON/A
_T ----~
�
I I! I I I p �i(P
Paae 3 of 3
DAVIE COUNTY ENVIRONMENTAL HEALTH
--• P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
OPERATION PERMIT
Account : 990004088 Tax:P.1NEH#: 5759-26-3026
Billed To: Charles &Naomi Hagerman Subdivisionanfo::,Div, of Michael Kelly Lot#'Tract
Reference Name: <LocationiAddress: Sanctuary Lane-27028
Proposed Facility: Residence ,; ;;' Pt6perty;Size: 10.95 acres
ATC Number: 6019
**NOTE**The issuance of this Operation Permit shall indicate the system described on the ATC 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.
System Type.: S.T.Manufacturer Tank Date Tank Size
Pump Tank Size Bedrooms:
System Installed By: Installer!# Date:
GPS Coordinate:
Environmental Health Specialist Date:
qUo
DCHD 11106(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street.
Mocksville,NC 27028
(336)753-6780/Fax#(336)753-1680
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account : 990004088Tax.P1NsFH#: 5759-26-3026
Billed To: Charles &Naomi Hagerman Subdivision info:,-. Div. of-Michael Kelly Lot#Tract,=3
. - Reference Name: LocationiAddress: Sanctuary Lane-27028
Proposed Facility: Residence Properly Size: 10.95 acres
ATC Number: 6019 .Site Type: ( New ❑Repair ❑Expansion
**NOTE**This Authorization to Construct(ATC)MUST BE ISSUED by the Davie County Environmental
Health Section prior tq issuance of any building permit(s),(in compliance with Article 11 of G:S.Chapter 130A
Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans,plat
or the intended use change. r/
Residential Specifications: #Bedrooms T #Bathrooms #People 3 Basement❑ Basement plumbingW
Non-Residential Specifications: Facility Type #People #Seats
Square Footage(or Dimensions of Facility)
Lot Size SQL Type of Water Supply: ❑County/City ZWell ❑Community Well
System Specifications: Design Was tewafer Flow(GPD)q Ftp Tank Size 1000 GAL.Pump Tank GAL.
Trench Width -ke Max.Trench Depths Rock DepthAV ,4 Linea_r Ft. LO' as%
Site Modifications/Conditions/Other: '
Contact the Davie County Environmental Health Section for final inspection of this system b tween
8:30=9:30a.m.on the day o stallation. Telephone#(336)751-8760.
pq�
Environmental Health Specialist Date: l
DCHD 11/06(Revised)
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
C�! 'LZ1P� Davie County Environmental Health
Q P.O.Box 848/210 Hospital Street
P Mocksville,NC 27028
JU
(336)753-6780/Fax(336)753-1680
Applica r: ❑ provement Pemut V/AAuthorization To Construct(ATC) ❑ Both
Type of ew System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPT,ICANT INFORMATION
Name P,�PtLZS J, ArA N T. AAGEAMOn Contact Person u�,s
Address c245 Home Phone
City/State/ZIP H\rf V S V I LLE Ems xlWr Business Phone ,a,
Email �tmeo17a +�CQpnl m4Ct1}'.wy))�
Name on Permit(ATC'if Different than Above
Mailing Address City/State/Zip
PROPERTY INFORMATION *Date House/Facility Comers Flagged
NOTE:. A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)1
(Permit is valid for 60 months with site plan,no expiration with complete plat.) ��►
Owner's Name•(;} ALts J. Ara WMI �WALn,M A o Phone Number
Owner's Address 945 S Al tr4 V I L L f Nei City/State/Zip ,91b g
Property Address !SO Ac,+114 1 city 4 S01LLT:
Lot Size I ,q'. Acres TaxPlN# 595UONRo
Subdivision Name(if applicable) Section/Lot#
Directions To Site: JSV gah4t)04b 51:'AiN f0d Ltfi4 bn4b 6111itin Lt--, - i;r14 b -oa,c 4vo L.q io
Dr,nd b V A tpn
Iftie answer to any of the following questions is-' es',supporting documentation must be attached:
Are there any existing wastewater systems on the site? Yes -No
Does the site contain jurisdictional wetlands? Yes •-No
1 Are there any easements or right-of-ways on the site? Yes Mo
Is the site subject to approval by another public agency? _Yes 1'No
Will wastewater other than domestic sewage be generated? Yes * No
IF RESIDENCE PITT,OT JT THF,BOX BFLOW
#People J #Bedrooms �_ #Bathrooms Garden Tub/Whirlpool &es ❑No
Basement: Ca'Yes ❑No Basement Plumbing: Rl!Yes ❑No 02 2,bq 1r15
IF.NON-RF.SIDF,NCR FIT J:,OUT THE BOX.BFd.,OW
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 consumption)
FOODSERVICE ONLY: #Seats
Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type: ❑ County/City.Water ❑New Well Axisting Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes F No
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 stakill the house/facili location,p o osed well location and the location of any other amenities.
-� � Site Revisit Charge
Propcily o er's or o is legs repres taiive sign e
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account# b
Revised 11/06 Invoice#
Appraisal Card - Page 1 of 1
DAVIE COUNTY NC 1/23/2013 12:09:33 PM
HAGERMAN CHARLES JEFFREY HAGERMAN NAOMI M Return/Appeal Notes: H6-000-00-020-03
SANCTUARY LN UNIQ IO 13492
2526978 - ID NO:5759263026
COUNTY TAX(100),FIRE TAX(100) CARD NO.1 of I
Reval Year:2013 Tax Year:2013 TRACT 3 MICHAEL KELLY S/D 10.950 AC SRC-
raised by 19 on 07/1 008 06004 ELISHA CREEK TW-06 C- EX-AT- LAST ACTION 20120622
CONSTRUCTION
DETAIL MARKET VALUE DEPRECIATION CORRELATION OF VALUE
m
OTAL POINT VALUE Eff. BASE
BUILDING USE MOD Area UAL RATE RCNEYB AYB REDENCE TO t
ADJUSTMENTS 97 00 %GOOD )EPR.BUILDING VALUE-CARD
OTALADJUSTMENT TYPE:Vacant DEPR.OB/XF VALUE-CARD 40,80
FACTOR MARKET LAND VALUE-CARD 79,73
OTAL QUALITY INDEX STORIES: TOTAL MARKET VALUE-CARD 120,53
OTAL APPRAISED VALUE-CARD 120,53 -�
OTAL APPRAISED VALUE-PARCEL 120,53
OTAL PRESENT USE VALUE-PARCEL 0
OTAL VALUE DEFERRED-PARCEL 0 =�
OTAL TAXABLE VALUE-PARCEL 120,530
PRIOR
BUILDING VALUE
BXF VALUE
ND VALUE 87,51
RESENT USE VALUE 0
DEFERRED VALUE 0
OTAL VALUE 87,510
PERMIT
CODE I DATE I NOTE I NUMBER AMOUNT
♦ OUT}WTRSHD:
SALES DATA
FF.
RECORD DATE DEED INDICATE SALES
LOOK IPAGE MOjYR TYPE / PRICE
0680 729 9 k001 WD UV 4000
0649 10491 2 120061 WD E I V
HEATED AREA
NOTES
r
w
OLD UNDER MARKETII _
SUBAREA UNIT ORIG% ANN DEP % OB/XF DEPR.
GS RPL ODE DESCRIPTIONLTH HUNIT PRICE COND BLDGlFL BAYS EYB RATE V GOND VALUE tr
TYPE AREA CS 25 BARN I 4CI 501 2,OOCI 24.0 00120081 S31 1 851 4080
FIREPLACE TOTAL OB XF VALUE 40,800
UBAREA o
OTALS °J
BUILDING DIMENSIONS ti
LAND INFORMATION
HIGHEST OTHER ADJUSTMENTS LAND TOTAL
NO BEST USE LOCAL FRON DEPTH/ LINE) COND AND NOTES RDA UNIT LAND UNT TOTAL ADJUSTED LAND LAND
SE CODE ZONING TAGE DEPT SIZE MOD FACT RF AC LC TO OT TYPE PRICE UNITS TYP ADJST UNIT PRICE VALUE NOTES
URAL AC 0120 100 1 649 1 1.1240 4 0.7900 O6-15+00+00+00 RT 8,200.0 10.95 .4 0.88 7,281.6 7973
OTAL MARKET LAND DATA - 10.95 79,73
OTAL PRESENT USE DATA
http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=H60000002003 1/23/2013
ITE EVALUATION/IMPROVEMENT PERMIT & ATC
avie County Health Department
2 5 2006 Environmental Health Section l
� p�G P.O. Box 848/210 Hospital Street 6b
' Mocksville,NC 27028
R�tyMEt��41� (336 751-8760/Fax 33 751-8786 `
psll pp�ytiCA ) (
Applic do Site Evaluation/Improvement Permit .Authorization To Construct(ATC) Both
***IMPORTANT'***THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed(%Or(esllvaoml,
er Contact Person
Billing Address P Q f3 tl;C a9 cF Home Phone 5
City/State/ZIP p J OC k,S V J'J J-- /1/C d 7.0a}$ Business Phone -
Name on Permit/AT f Differ nt than Above
Mailing Address ,42, City/State/Zip 4 C4
PROPERTY INFORMATION
NOTE: A survey-plat or site plan must accompany this application.
(Permit is valid for 60 months with site plan,no expiration with complete plat.)
Street Address T rad' 3 Lctn2.City - S VJ(Q- Tax PIN#,i 5 2430ah
ubdivision Name ' ,cJ i - efction/Lot# a O Lot Size (3, q Cot
Directions To Site:
5M be Y I
Date House/Facility Corners.Flagged —o!v LUf t »'txnS��jYts
} If the answer to any of the following questions is"yes",supporting documentation ust be attached.
Are there any existing wastewater systems on the site? ❑Yes O} a0µq X 1,93X Iv,I X
Does the site contain jurisdictional wetlands? -1 es ( 0 (�(�D x
Are there any easements or right-of-ways on the site? fres ❑No 1 A
Is the site subject to approval by another public agency? ❑Yes lido ?
Will wastewater other than domestic sewage be generated? ❑YesXNo
7C WjckfeZ �BZly ��
IF RESIDENCE FILL OUT THE BOX BELOW
#People 3 #Bedrooms ##BathroomsGarden Tub Whirlpool Yes ❑No
Basement: Yes ❑No Basement Plum ing: Yes ❑No ;-1-P
IF NON- ENCE FILL O HE BO ELOW
Type of F ili usiness Total Squar o e of Building #Peo
#Sin Commodes #Showers #Urinal
Es ' ated Water Usage allons day) ach d umentation ma ar fa 'lity w consump ' n)
O0 SERVICE ONL\Y. # is
Type system requested: , conventional ❑Accepted ❑Innovative ❑Altemative. ❑Other
Water Supply Typek County/City Water ❑New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes No
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. 1 understand that I am responsible for all charges incurred
from this application. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to
conduct necessary inspections to Mdetn1comp Lance th ap icable la nd rules on the above described property located in
Davie County and owned by
i.;
rty owner's or owner's legal repres tative signature Site Revisit Charge
0 ,r Client Client Notification Date:
Dat EHS:
Sign given P' es ❑No / Account# �d D
• Revised 2/06 I �}D�� ���� Invoice#
�� Q..�� QO.�t.Z 98" -•
�.
CEATIPICATE OF Amru_tCY e[yAPMxG SURVEYOR CERTIFICATION 1'OR EVBOM910N-DAME COUNTS.NC peOTlRx OP ORD!flMMO ST.Mer" oe
L+NLMM A...CE 11 THAT 1HI5 PIAT WAS DRAWN UNDER L Wllllw A BI..1on Pro/.00lon.l Lend Sur.gor.Numbs L-4219-Ad,to No \ PROPOrrY(AVE FMLOW MW for R.,fttrollee At�Z s'elxk LII. • ,
MY SUPERVISION FROM AN ACTUAL SURVEY MADE UNDER MY 11.11-.,of Ind{C.IW IF
.v X. C'ENTERLAME OF CREW .
SUPERVISION(DEED DESCRIPTION SIION ON PIAT):THAT TBE y M 40 A29 2D06.nd Ttcord.d N
C�
BOUNDARIES NOT SURVEYED ARE Sf10Wx AS BROKEN LINE!PLOTTED !S_d. Tb.l Ihl.plot M of.tuner o:on.lbrt t.l.w7•ruck..Iba t +
FROM INFORMATION FOUND IN DEEDS A3 LISTED.THAT THE RATIO ..b—u..of rV J. P.rcolt..eourl-`M rurr.T•or CEDAR Plot Boek P_
OP PRECISION AS CALCUIATED 13 1,10.ODOt:TINT THIS MAP WAS elks.u.llev to lM IuuUoo el..ubdW...: ROODS MANCA IGR�
PR[PARED IN ACCORDANCC WITH G!.47-00 AS AMENDED. �� gIsOIOo oa 105 PC 437 /
Ty !W HAND AND OFFICIAL Sm TSI!Z@ rL DAT or Root_ -je1��=� DB 113 PC 262
J4/N SITEA\U' 1A�Ya3! S rn7or DATE TAX O-G600000D01 M.Brtot SkaJ- ewt ounlT P.Eitlx el Derdt .
RO, �C3vr�yRV"'J9 SP
L 4219
.� LICENSE N0. PROFESSIONAL LAND SURVEYOR —
6
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DISTRIBUTED BY COMPASS BULL GILIM H.MOCLAVROCE R®AR / 4 \o�o�
DB 112 C 157 \j
2. AREA DETERMINED BY COOROIXP
A76 COMPUTATIONS. 4 `1'
TAX ID-X500000051
S. DREIPRESENT INFORMATION TAKEN FROM F—F / F \ / •s\Al V i
DEW
INtl REDR Put. / / 4 � 7 / 5�5g1� rr
4. PROPERTY TONED G 1 Fes_F j I L
S. DISTANCES INOWN ARE HORIEONTAL GROUND DISTANCES- / I I /
US SURVEY FOOT UNLESS NOTED OTIFERNI3L. / 'QCT-9 BYNDEY R.AT
6. THIS PROF""0 M 2011E A,SPLCWL FLOOD NAGRD !'I AREA-10.94Z ACRES 5 ^ ED[DLND J.SEYMOUR -
BAG MUNDAA ELEVATION tX6 AVE O NI flDOD WNED.NO / In j / / I I DB 202 PG 769
AAS,IN.MD EDBY9 HAVE EAR DLTEIODNER (•I IQCHAII.J.RI:I.1EY -T \ .T" rj TAX B 202 C 769 - r
ACCORDING TO IT I.R.M.FARM N0.3TOSOB0100-C F DB 646 PC 591 TT
EFFZC DATE 12/17/90. CAROL SHEETS At � � TAX ID-H600000020
LL
T. TINS SURVEY IS SU MECT M ANY AND AYAM THAT MY JEAN MOYNIHAN - REMAINING AREA-32936 ACRES /
BR DISOMM BY A FULL YTYM SEARCH.WHICH HAS NOT OB 152 PG 357 yD• ARIA MSIOE R4* 1.717 ACRES / PROPERTY LINE TABLE L39 5331805
BEER NPNISITED TO WNVEYOA AS OF TRIS NTE. TAX+D-H60000D0170{ TOTAL AREA B4.B69 ACRES j>t LINE lENC1H BEARING L40
6. SURVEYOR DOES NOT CSRTUY TO TN6 LOCATION.PRESENCE. ,t LI L11
OR ABSENCE OF ANY UNDERGROUND STNUCTURES.CRAVCEITES. I• N �ArW L43 ,
UTIWIE9.OR THE LIKG WHERE TNERE WAS NOT VLSIBIE �� �bYW L1 1 L44
CMDENCE INDICATING SUCH OBSERVED WHnd PERFORMING W moT
THE SURVEY. 56876�45� �•1fj14j1� / / L5 { L453111* OMWE
�_,
9. ALL EXISTING IRON PIPE DIMENSIONS ARE OUTER DLUU= � �� .199.76' /4'OP 6 6'G�V� � NEW 1w / LT 4• C4_8
10.UNDERGROUND UILITITS,TELUHOKE AND WATER ALONG WITH ,
OVERHEAD UTR.ITDS ARE EVIDENT ALONG SANCTUARY LANE. �) 17•DS'E //FOLLOY/5 C/L L49
CONNEMIVITS HAS NOT BEEN SHOWN. I � / DRAINAGE TCN /y U LAB
It.I&A 19 OF BLARING AND NC GRID(NAD B9k00RDMATE3, (y9�{ 02 1 L10 { L50
ESTABLISHED BY GPS(RTK METHODS).USING A NCGS CORS <^ I jV+ 'I'Ef1 J.ROBERTSON L11 L51 4'
VIRTUAL REFERENCE STATION SOLUTION.COMBINED GRID CAROL SHEETS At '�E /o g Lt2 L52 1
I AREA�10.265 ACRES .{r,QAI OD D6 PO NO
FACTOR-049991009. JEAN MOYNDlAN Z$ yI / sY a TAX ID-X600000079 L73 L33 2!L79' S7115510
DB 513 PC 656 '( I"�¢ f / db L15 L55 '
RSR'aeNCT9'
TAX lo-X60000056 In Sj B �, L14 L55 •W
1. ATI.DELA!AND MAPS 51K)"HEREON. I2 � �. L� / / L76 LS6 1 1Y
xe 10E FO110R5 c OF L17 4 L57 1
-No ApPreTol 1 M N. H CoueIF Plonnint DrpArL.-t' kOF I DRAINAGE\DITp1 I' L10 LSB
EB \ AL10 LBO
PMTm Dlroclor L21 47.ar Lei 51.11,
E4-51 i CONTROL
CORNER ( !P•o I � 4^ JAT$J�//
L23 n4T• L63
REVIEW OMMM'S'9 ClRTRICATE E I3317HJ.SJ F/_ T L24 L64 41
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to
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mew or net a rt.tnlyy .m.n4 f.r r«Oram,• I L27 LV
STEVEN M.t DEBRA ANN DUCK `1 10 ,1 .•f L28 Lea t
RrM Omar JA� DB 497 PG 493 Q�p �j L2933613'•• { L69
TAX ID-H60000001702 l3017,90 L70
TRACT-1 LM L71
L32 115,02- L72 N45M'27'E I
— EB AREA11.411 ACRES Sa'prj`•{ r / / Ly3 L73
job.93 AREA w A/rrar T Aars A7 / L34 an' S32'W= L74 4mas
1 I rcr MRA_1LTa AUEs 1 / L35 1' L78
LEGEND d �A ��( \
EASTING PON PIPE 0 ESP • . \ EI L36 L76
EXISTING IRON ROD O EIN '17ERRY ALFRED t $ '�3 IQA� / / / L37 7 Y l77
NON-MONUMENTED POINT X LINDA CALDIFELL CALL q "d 1 p� DRAIN
/ / L79 19. SS116'S9
IRON REBAR SET • DB 201 PC 692
TELEPHONE PEDESTAL p
TAX
o-H6D00000nol �� 1 _I - FINAL PLAT.
r
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POLE AY O C (1 i3,� /
FIRE HYDRANT � YfA Ilii 1 -t CONTROL GEp^flCATE DP OWNERSHIP AND DEDICATION: � DIVISION OF MICHAEL Jr.
WATER METER 1M J 1 UL7COWEP LIN)Mrrbr ce Ufr U"t 1 Am(w ATO MI o.n.r(.)of the port?doo..WWATER VALVE •wv ADDITIONAL 20'INGRESS.EGRESS, �a'• +! b.rtoa..Id<h b locetea In Me eAbdMafon Iurisdi.U-of D.Z CouotT. th.t LALLY PROPERTY
WELL REGRESS AUTUTY EASEMENT 4d`% r. h,mbr.dopt thio r WMue.pl.'
.ilb mr ir..t_Ue,trtcbwkW mwmnm
ELECTRIC METER ® LOCATED EAST OF EXISTING 30• 1 p�T bundle,ootb.ek Datr..d dWie.tt 11.t—to(rwdt)..Btro. Ib.pvb and oth.,
RICHT-OF-WAY R/W EASEMENT(50'TOTAL) ,W 4'
S� ltt d.otemmte to pubU,er P to to& r OWNER: -
CONCRETE MONUMENT CM / M'CHACL J.KELLY
CHORD CH �� TE N�1'JF�/
SIGHT EASEMENT SE �� e�'Et4 I116.S4 —
DEED BOOK DB Ar / / Ml O.nn(a) TAX ID-X600000020
PIAT BOOK PB REBA
/ DEED BOOK 649 PACE 591
CURB AND CUTTER CAG OIIJLRL.FS x't 68.055 ACRES�/-(TOTAL)
REINFORCED CONC PIPE RCP C) H.WOODLLIJI?
CORRUGATED METAL PIPE CMP NIS06,0T'W� A} DB 142 PG 546
CORRUGATED PLASTIC PIPE CPP �7�, TAX ID-H600000018 Allied Associates P.A.
BWNOAPY LINE _ WI I,TAM S.t EAY M.SAIEY 1 A` 4210 In._SAA UMEUL ROAD Plw,.(l]d1163-]LTi
RIGHT-OF-WAY LINE OB 561 PG 271 / lT\WN�-glove-wgrwV.clwnOT i'Ot 160-eee6
UNSURVEYED PROPERTY LINE TAX ID-He0D000M7 GRAPHIC SCALE ~�
FENCE UNE N13VS.ER W AR
. EDGE OF GRAVEL 5292 No, 1. mp .pp SCALE TONNsw CO STAT[ 0.1E
EDC,OF PAVEMENT FP 4f,E 1-•200' MOCKSMUF DAME NORTH CAROLINA 3/23/06
CA STREAM OR WATER BODY t''
100-YEAR FLOOD(SCALED) �F—F— T% SOPV[1E6. —&. 306 N0. MAP xo. Tp3
NIn>wt WAS/DW WAR - PA060301
OVERHEAD UTILITY —pW AaT;.•��r (1N FEET
EASEMENT ----� �_ C/L YIUING D.
1 Inch s 200 IL - ® A a A—,Fw 2006
F AM R
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Davie County Online GIS Print Page
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*****WARNING:THIS IS NOT A SURVEYI Date: 8/24/2006 Rec
***** Parcel L2525882
0002003
This map is prepared for the inventory of real Number
PIN
property found within this jurisdiction,and is Number63025
compiled from recorded deeds,plats,and other Account
public records and data Users of this map are umber
hereby notified that the aforementioned public tedr s1 KELLY MICHAEL J
primary information sources should be consulted for tad
verification of the information contained on this r#2
map.The County assumes no legal responsibility slung BOX saa
for the information contained on this map. dress 1
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: 990004088 Tax PIN/EH#: 5759-26-3026
Billed To: Charles&Naomi Hagerman Subdivision Info: Div.of Michael Kelly Lot#Tract-3
Reference Name: Location/Address: Sanctuary Lane-270 8
Proposed Facility: Residence Property Size: 10.95 acres Date Evaluated: tS— e L
Water Supply: On-Site Well Community Public t
Evaluation By: Auger Boring 3 Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position L
Slope%
HORIZON I DEPTH -
Texture group N__ G(�
Consistence 44-MIr
Structure UL
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH �p
. Texture grouG{
Consistence
Structure
Mineralogy _
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL',WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE .Z S
SITE CLASSIFICATION: EVALUATION BY: V l✓�
LONG-TERM ACCEPTANCE'RATE: " 0 • �� OTHER(S)PRESENT-: t�
REMARKS: r�u s
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
ONSIST .N . ,
VFR Very friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm
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 I
Mineralogy /
1:1,2:1,Mixed,
Horizon depth-In inches
Depth of fill-In inches I
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 05/05 i.�
•
0
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Davie County Health Department
Environmental Health Section
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
(336)751-8760/Fax (336)751-8786
Improvement Permit
Charles and Naomi Hagerman
PO Box 1294
Mocksville,NC 27028
Re: 10.947 Acre Tract/Sanctuary Lane
Tax PIN# 5759263026
Dear Client(s):
This Improvement Permit DOES NOT authorize the construction of a wastewater system. An
Authorization To Construct a wastewater system must be obtained from this office prior to the
construction/installation of a wastewater system or the issuance of a building permit(in compliance with
Article 11 of G.S.Chapter.130A,Wastewater Systems). This Improvement Permit is subject to revocation if
site plans or the intended use change.
System To Serve: !->11DbNCP(Vastewater Design Flow(GPD): Valid: Z5 Years ❑No Expiration
` System Type: conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Site Modifications/Permit Conditions:
AMx iW
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