1128 Williams Rd, �
Davie Countv, NC
10 91
Tax Parcel Report
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Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage:
Deed Date:
Deed Book 1 Page:
Plat Book:
Plat Page:
Building Value:
Tuesday, October 1 l, 2016
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WARNING: THIS IS NOT A SURVEY
Parcel Information
170000004301 Township:
5778164856 Municipality:
62423960 Census Tract:
ROMINGER JEFFREY W Voting Precinct:
1128 WILLIAMS ROAD Planning Jurisdiction:
ADVANCE Zoning Class:
Land Value:
Total Assessed Value:
NC Zoning Overlay:
27006-0000 Voluntary Ag. District:
1.28 AC WILLIAMS RD Fire Response District:
1.18 Elementary School Zone:
3/1999 Middie School Zone:
002100738 Soil Types:
Flood Zone:
Watershed Overlay:
150630.00 Outbuilding 8� Extra
Freatures Value:
22260.00 Total Market Value:
214540.00
9"�'�' Davie County,
°o�„��' NC
Fulton
37059-804
FULTON
Davie County
DAVIE COUNTY R-A
No
FORK
CORNATZER
WILLIAM ELLIS
WeC, Pc62
DAVIE COUNTY
41650.00
214540.00
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Davie County Health Department
Environmental Health Section
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Phone: (336) - 753 - 6780
P.O. Box 848
210 Hospital Street
Courier # : 09-40-06
Mocksville, NC 27028
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
I'ax: (336) - 753-1680
Name: ! � � � G�Jh � / �• � fi n n..1..2.��^ � � Phone Number �-�� ' � �'1 � � � % v,� (Home)
Mailing Address: Z / g • �i�l%i.� � /Ld�- (Wark)
///L�G�,Sdi ��e i✓C. �7Q2� Email Address: /n,�G�i.ti 1��s2,S � �7` n^ ^ ► ��C9 �
Detailed Directions To Site: b�l �'+ l� ���' J �'�^�^ �L 'Z� �� � o,� �✓� ��'�4n �U C
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Property Address: /�,2- �.�% � tk�'�'L.i �-�.Q 0 . Sd � L /� C .Z % � �.
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: ,.1���� ��/P/�s ��� ��Type Of Facility:
Date System Installed (Month/Date/Year): Number Of Bedrooms: � Number Of People: �
Is The Facility Currently Vacant? Yes � If Yes, For How Long7
Any Known Problems7 Yes � If Yes, Explain:
Please Fill In The ollowing Information About The NEW Facility: .
Type Of Facility: et�(�,G�(�- Number Of Bedrooms: Number of People
Pool Size: Garage Size: ,�Q jC � i� Other:
Requested By: ('/V �[ �L Date Requested: � � 7 �/ �J
(Signature)
For Environmental Health Office Use Only
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Environmental Health Specialist
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*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:$
Paid By:_
Account #:
Received By:
#:
Date:
Da�ie County Health Deparbment ��
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pA� En_ 'ronmental Health Sectio�/
'�` P:O. Box 848
�`�� 210 Hospital Street
vc� `
Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 751 - 8786
Name: / � � «� �/Z �/U l � � �'� (Home
� Phone Number )
Mailing Address: � ��O , � � � " � (Work)
, i/<� Emai1�1����ii���G�f/��/�%f �D'/l�l
Property Address: 2 /�lj� J��s '
Please Fill In The Following Information.About The EXISTING Facility: �7' a� �- ��' ��3' �I
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Name System Installed Under. Q d L .�'�'ype 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 � o If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type OfFacility: Number OfBedrooms: �Number ofPeople
�equested By: � Date Requested: 2.. " �j • � � •
ignature) ,
For Environmental Health Office Use Only
A proved Disapproved
Comments:
Environmental Health Specialist
Date: � — / 7— �
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
or limited) that the on-site wastewater system will function properly for any given period of time.
PaYme : Cash heck Money Order # Amount:$_
Paid By; �������% � Received By:_
Account #: �/) ) � i Cl Invoice #:
Date:
Davi�e Cpunty, NC
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WARNING: THIS
Parcel lr
Parcei Number: 170000004301 Township:
`�/ ., DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
_- ``NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
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Name a -, '�'. , . ;�� , — Date `�� � r � � � ?P ��.� �
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Subdivision Name Lot No. Sec. or Block No.
Lot Size %`� ��t House �� Mobile Home _ Business �— Speculation
No. Bedrooms rJ No. Baths _� % No. in Family �-'
Garbage Disposal YES {] NO p� Specifications for System:
Auto Dish Washer YES p NO ❑ � �,�
Auto Wash Machine YES �] NO ❑ ' � � � '� � �
Type Water SuPP�Y ,�f, -- , ���' � � ' � � �'/
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
'Contact a representative of the Davie Cou
9:30 A.M. or 7:00-1:30 P.M. on day of c�
Final Installation Diagram:
Improvements permit by —�������
ealth
tion.
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for final inspection of this system between 8:30-
umber: 704-634-5985.
nstatled by ``�-�,� �-*�'�'��
b
Certificate of Completion � - ��^-�-��� Date � � � 1 � `
'The signing of this certificate shall indicate that the system described above has been instalied in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guaraniee that the system will function
satisfactorily for any given period of time,
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. ;Y�': � -� '• ' DAVIE COUNTY HEALTH DEPARTMENT
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-- _�, IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"'NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
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Name - , % `, -� _ �' �" _ Date ` ` %� , _ . ,. .�� :
Location , �i , ', �, , ,;: _- / _-. ,:
/.�/.'��A.. � sJ D� ,%� . . - . . - � � - I � � a l�i; !1,��-�n,t /�/.l�,
Subdivision Name Lot No. Sec. or Block No.
Lot Size %, Y!�l�_� House �-� Mobile Home _ Business _— Speculation
No. Bedrooms _ No. Baths �� .�'�-2 No. in Family �"=
Garbage Disposal YES ❑ NO �.� Specifications for System:
Auto Dish Washer YES p NO ❑ -
Auto Wash Machine YES � NO ❑ 1'� �'` �`�
Type Water Supply �1 --- �,� ��,,,�,' ��' �� , .i 1 -� ��
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by _�%� �� -'=-r` �c
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*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:
System Installed by ��� � ��
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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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
� Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By—
2. Address ���
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3. Property Owner if Different than Above
Add ress
4. Permit To: a) Install J Alter Repair
b) Privy Conventional Other Type
Ground Absorption
C' .
Home Phone �9�- `� / � o
Business Phone -S�m �
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House �Mobile Home Business
Industry Other
b) Number of people Jr
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions `� 9 � 2- �
Bed Rooms—� Bath Rooms 2�v Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc. �
Estimate amount of waste dai4y (24 hours),
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7. Number and type of water-using fixtures: � .
commodes -3 urinals � garbage disposal
lavatory � showers � washing machine �
dishwasher sinks Z"
8. a) Type water supply: Public '� Private Community
b) Has the water supply system been approved? Yes ✓No
9. a) Property Dimensions /7 9� 3b i
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? y�
What type?
This is to certify that the information is correct to the best of my knowledge.
9-�� - � � . %�, ��. '
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82)
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Name_
Address
1) Topography/Landscape Position
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
3) Soil Structure (12-36 in.)
Clayey Soiis
4) Soil Depth (inches)
5) Soil Drainage: Internal
Externai
6) Restrictive Horizons
7) Avaitable Space
8) Other (Specify)
9) Site Classification
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
� SOIL/SITE EVALUATION
Date ��j
Lot Size- ,_,
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PS
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EA 2
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US
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PS
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PS
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PS
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PS
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PS
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AREA 3
S
US
S
PS
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S
PS
U
PS
U
S
PS
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PS
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PS
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U—UNSUITABLE S—SUITABLE APS—Provisionaliy Suitable
Recommendations/Comments:
Described by �,�.;r�'�� Title ---a�� Date
SITE DIAGRAM
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