774 Williams Rd i
Davie County,NC Tax Parcel Report Wednesday, February 15, 2017
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WARNING: THIS IS NOT A SURVEY
Parcel,Inforniation = _
Parcel Number: 1700000032 Township: Fulton
NCPIN Number: 5768667498 Municipality:
Account Number: 79819190 Census Tract: 37059-804
Listed Owner 1: WILLIAMS TINA ELAINE Voting Precinct: FULTON
Mailing Address 1: 774 WILLIAMS RD Planning Jurisdiction: Davie County
City: ADVANCE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27006 Voluntary Ag.District: No
Legal Description: 19.58 AC WILLIAMS RD Fire Response District: FORK
Assessed Acreage: 18.52 Elementary School Zone: CORNATZER
Deed Date: 5/1996 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 001870556 Soil Types: GnB2,GnC2,EnB,MsD
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 242060.00 Outbuilding&Extra 6140.00
Freatures Value:
Land Value: 156430.00 Total Market Value: 404630.00
Total Assessed Value: 404630.00
All data Is provided as Is without warranty or guarantee of any kind 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
"OU Nit NC or arising out of the use or Inability to use the GIS data provided by this website.
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OPERATION PERMIT or ice use unly
,. Davie County Health Department *CDP File Number 139268-1
210 Hospital Street
P.O. Box 848 County ID Number.
Mocksville NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township
Applicant: Tina Williams C:Address:
operty Owner: Tina Williams
Address: 776 Williams 776 Williams
City: Advance ty: Advance
StatefZip: NC 27006 State2ip: NC 27006
Phone#: (336)998-3394 Phone#: (336)998-3394
Propertv Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
774 Williams Rd
Advance NC 27006 Directions
= = H '64 East to Cornatzer Rd. tum left to Williams
structure SINGLE FAMILY Rd urn right to 776 williams on Right
of Bedrooms: 3
° #of People:
*Water Supply: NIA
*IP Issued by 2140-Nations,Robert
*System Classification/Description:
TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS
*CA issued by:, 2140-Natons,Robert
SaproliteSystem? OYes QNo
Design Flow: 3 6 Q} *Distribution Type: GRAVITY-SERIAL Pump Required?
SOiIQYes (E)No Rate: 0 - 3
*Pre Treatment:
Drain field
rNo.
tion Field <- 1 a 0 0 Sq.ft. *System Type: INFILTRATOR QUICK 4 STANDARD
ain Lines 3 Installer: Brian McDaniel
Total Trench Length: 3 0 0 ft. Certification#: 1118
Trench Spacing: _ a ()Inches O.C.
Feet O.C. EH S: 2140-Nations.Robert
Trench Width: _ 3 inches
Feet Date: 1 0 / x 6 / 2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6 Inches
Minimum Soil Cover. 4 inches Approval Status
Maximum Trench Depth: 3 6 Inches ®=,Approved0 Disapproved
Maximum Soil Cover:
2 4 Inches
T .
CDP File Number 139268- 1 Septic Tank County ID Number:
Manufacturer. Shoaf Let.
Long:
STB: 760
Gallons:
1000 Installer Brian McDaniel
- Certification#: 1118
Date: 0 8 / 0 a / a 0 1 6
` J *EHS: 2140-Nations.Robert
*Filter Brand: POLYLOK PLA 22 With Pipe Adapter
ST Marker: El Yes E No
Date: 1 a 6 / 2 0 1 6
. 0 /
Reinforced Tank: E] Yes ® NO Approval Status
1 Piece Tank: ❑ Yes ® No ® approved❑ alsapprove
Pump Tank
Manufacturer Installer. --
PT: Certification#:
_Gallons: *EHS:
-. _..Date: / / Date.
RiserSealed ❑ Yes ❑ No -
RiserHeght. ❑ YeS = ❑ NO (Min.6 in.)
f,.
Approval Sta#us
Reinforced Tank; ❑. Yes OU..No _. Q Approved❑ Dlsap roved
1 piece Tank: ❑ Yes_ ❑y No
_ -
- Supply Line
Pipe Size: inch diameter Installer:
Pipe Length: feet Certification#:
* -
*Schedule: EHS:
Pressure Rated [I Yes ❑ No Date:
Approved fittings ❑ Yes ❑ NO Approval Status
❑ Approved Q Disapproved
eu
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 ApprcivrW,Status
PVC unions E] Yes C1 No ❑ roved El Disapproved;
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes. ❑ NO
CDP file Number 139268 - 1 County ID Number:
Electric Equipment
N�4X or Equivalent ❑ Yes ❑ No Installer;
Box 12 inches Above Grade ❑ Yes ❑ No
Certification#:
Box Adj. Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No *EHS:
Pump Manually Operable ❑ Yes ❑ No
*Activation Method: Date:
Approval Status
Alarm Audible ❑ Yes ❑ No
n
�❑ Approved D Dlsappror�ed
Alarm Visible ❑ Yes ❑ NO
2140•Nations,Robert
*Operation Permit completed by:
_ Authorized State Age Date of Issue: 1 0 / a 6 / a 0 1 6
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;l5A-NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.This property is served by a TYPE al G. sewage septic system.
Rule.1961 requires that a Type TYPE III G• septic system meet the following criteria:
Minimum System Review ByThe local Health Department: wA
_. Management Entity: OWNER
Minimum,System InspectioniMaintenance FrequencyByCertified Operator:
WA
Reporting Frequency By Certified Operator: NIA
Role.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entityw1h 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 entily 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 ownerand 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 41mport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 139268 _ 1
Davie County Health Department CDP File Number.
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch
Drawing Drawing Type:-Operation Permit Scale: QBlock
Q N!A
1
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41
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CONSTRUCION For office Use only
• - ' AUTHORIZATION *CDP File Number 139268-1
Davie County Health Department County ID Number.
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 3 / a 0 a 1
Applicant: Tina Williams Property Owner: Tina Williams
Address: 776 Williams Address: 776 Williams
City: Advance City: Advance
State/Zip: NC 27006 State/Zip: NC 27006
Phone#: (336)998-3394 Phone#: (336)998-3394
Property Location & Site Information
r77
ressfRoad #: Subdivision: Phase: Lot:
4 Williams Rd
vance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 East to Cornatzer Rd. turn left to Williams Rd. turn
right to 776 williams on Right
#of Bedrooms: 3
#of People:
*Water Supply: NIA
- System Specifications
Minimum Trench Depth: a 4
(Site Classification: Provisionally suitable Inches
Sa rolite System? Minimum Soil Cover. 1 .2
p y QYes @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: Q Yes O No
Pump Required: QYes QNo OMay Be Required
Nitrification Field 1 a 0 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines 3 1-Piece: QYes ONo
Total Trench Length: 3 0 0 ft GPM—vs— ft. TDH
Trench Spacing: 9 Inches
O.C.nches O.C.
_ Dosing Volume: _ Gallons
Trench Width: — 3 Q Inches
Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre-Treatment: ONSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: OI 011 0111 OIV
Donn 1 of Z
CDP File Number 139268 - 1 CounVID Number. C
❑ Open Pump System Sheet
Repair System Required:@Yes ONo ONO, but has Available Space
rDesign
System
Trench Spacing: 9 &130
Inches O.0ification: Provisionally Suitable — Feet O.C.
Trench Width: Inches
w: 3 6 0 — 3 Feet
SoilAggregate Depth:
Application Rate: 0 3 inches
*System Classification/Description: Minimum Trench Depth: a 4 Inches
TYPE II 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
Ntrification Field 1 a 0 0 Sq.ft. Maximum Soil Cover: a 4 Inches
No. Drain Lines 3 *Distribution Type: GRAVITY-SERIAL
Total Trench Length: 3 0 0 ft Pump Required: QYes @No 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.
"Permit Conditions
The issuance of this permit bythe 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. ;
This Authorization for Wastewater System Construction shall be valid fora person equal to the period of validity of the improvement Permit,not
to exceed five years,and may be issued at the sametime the Improvement Penult 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 Constriction
Authorization is found to have been incorrect,falsified or changed,or the site is altered,the permitor 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 a Date:_
*issued By: 2140-Nations,Robert Date of Issue: . 0 4 / 1 3 / a 0 1 6
Authorized State Agent: Malfunction Log OYes #;
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• I ,CONSTRUCTION AUTHORIZATION 139268 - 1
• , Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 04 / 1 3 / 0 1 6
Q Inch
0131oDrawing Drawing Type: Construction Authorization Scale: , ON/A = ft.
pNra
!
CONSTRUCTION AUTHORIZATION a }
Davie County Health Department
210 Hospital Street CDP File Number: 139268
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: _0 .4 1 1 3 1 2 0 1 6
Click below to import an image from an external location: Drawing Type:Construction Authorization
CONSTRUC-MON For office Use Only
AUTHORIZATION *CDP File Number 139268-1
Davie County Health Department County ID Number.
'f ' 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 9 / 1 6 / .2 0 1 9
Applicant: Tina Williams Property Owner. Tina Williams
Address: 776 Williams Address: 776 Williams
City: Advance City: Advance
StatefZip: NC 27006 State/Zip: NC 27006
Phone#: (336)998-3394 Phone#: (336)998-3394
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Williams Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 East to Cornatzer Rd. turn left to Williams Rd. turn
right to 776 williams on Right
#of Bedrooms: 3
#of People:
'Water Supply: NIA
System Specifications
CF1owMinimum Trench Depth: a 4
:
Provisionally Suitable Inches -
Minimum Soil Cover.
QYes @No 1 a Inches
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-PARALLEL(eq.d-box)
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
1 0 0 0 Gallons
*Proposed System: 25%REDUCTION 1-Piece: QYes QNo
Pump Required: QYes ®No OMay Be Required
Nitrification Field 1 a 0 0 Sq. ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: QYes ONo
Total Trench Length: 3 0 0 ftGPM—vs— ft. TDH
Trench Spacing: 9 Inches O.C.
_ Feet O.C. Dosing Volume: _ Gallons
Trench Width: Inches
— 3 . Feet Grease Trap: Lallons
Aggregate Depth: inches
Pre-Treatment: ONSF OTS-1TS-II
Septic Tank Installer Grade Level Required: OI Oil OIII
Pagel of 3
` CDP File Number 139268 - 1. County ID Number:
❑ Open Pump System Sheet
Repair System Required:OYes ONO QNo, but has Available Space
epair System
Trench Spacing: Q Inches O.C.
"Site Classification: Provisionally suitable 9 e Feet O.C.
Width:dth: Inches
Design Flow: 3 6 0 3 8 Feet
Soil Application Rate: 0 _ 3 Aggregate Depth: inches
Minimum Trench Depth: a 4 Inches
'System Classification/Description:
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches
Maximum Trench Depth: 3 6 Inches
'Proposed System: 25%REDUCTION
Maximum Soil Cover:
Nitrification Field 1 x 0 0 a 4 Inches
Sq. ft.
'Distribution Type: GRAVITY-PARALLEL(eq.d-box)
No. Drain Lines 4
7otalTrench Length: 3 � � ft Pump Required: QYes QNo QMay Be Required
Pre-Treatment: ONSF 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. �•
7
"Permit Conditions
The issuance of this permit bythe 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. 0.
no
2,
This Authorization for Wastewater System Construction shall bevalid for a person equal to the period of validity of the Improvement Pennit,not
to exceed five years,and may be issued atthe sametime the Improvement Permit issued(NCGS 130A-336(b)�If theinstallation 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 cr 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? QYes ONO
Applicant/Legal Reps. Signatures Date:.
'Issued By: 2140-Nations,Robert Date of Issue: . 0 9 1 6 / .2 0 1 4
Authorized State Agent: Malfunction Log QYes
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
wrvZ$ I KULMON AUTHORIZATION
Davie County Health Department CDP File Number: 139268 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 9 1 1 6 1 2 0 1 4
Qlnch
Drawing Drawing Type: Construction Authorization Scale: (OBlock ft,
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Paae 3 of 3
CONSTRUCTION For Office Use Only
AUTHORIZATION "CDP File Number 139268-1
Davie County Health Department
County ID Number.
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 9 / 1 6 / a 0 1 9
Applicant: Tina Williams Property Owner. Tina Williams
Address: 776 Williams Address: 776 Williams
City: Advance City: Advance
StatefZip: NC 27006 State/Zip: NC 27006
Phone#: (336)998-3394 Phone#: (336)998-3394
Property Location &Site Information
Address/Road#: Subdivision: Phase: Lot:
Williams Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 East to Comatzer Rd.tum left to Williams Rd.
#of Bedrooms: 3 tum right to 776 williams on Right
#of People:
'Water Supply: N/A
System Specifications
Minimum Trench Depth: a 4
Site Classification: Provisionally suitable Inches
Minimum Soil Cover.
Saprolite System? O Yes 9 No 1 a 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-PARALLEL(eq.d-box)
TYPE 11 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 a 0 0
Sq.ft. Pump Tank: Gallons
No. Drain Lines 4 1-Piece: OYes 0 N
Total Trench Length: 3 0 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: inches
Pre-Treatment: O NSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01011 O III 01V
Page 1 of 3
•CDP File Number 139268 _' 1 County ID Number.
• • ❑ Open Pump System Sheet
Repair System Required:®Yes ONO ONO, but has Available Space
rDesignFlow:
System
Trench Spacing: 9 O Inches O. .
ification: Provisionally suitable — ®Feet O.C.
Trench Width: 3 O Inches
3 6 0 — _ ®Feet
Soil Application Rate: 0 3 Aggregate Depth: inches
u
*System Minimum Trench Depth: a 4 Classification/Description: Inches
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR Minimum Soil Cover:
LESS) 1 a Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Nitrification Field 1 a 0 0 Sq.ft. Maximum Soil Cover. a 4 Inches
No. Drain Lines 4 *Distribution Type: GRAVITY-PARALLEL(eq.d-box)
Total Trench Length: 3 0 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. a 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 m�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 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(9)).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
Applicariftegal Reps. Signature: Date:
*Issued By: 2140-Nations,Robert Date of Issue: 0 9 / 1 6 / 22 0 1 4
Authorized State Agent: Malfunction Log Oyes
(9)Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• .CONSTRUCTION AUTHORIZATION 139268 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 09 / 16 / .2014
O Inch
Drawing Drawing Type: Construction Authorization Scale: , O Block
O N/A
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A.
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CPO
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0
x
Page 3 of 3
P1 P2
CONSTRUCTION For office use Only
AUTHORIZATION *CDP File Number 139268-1
Davie County Health Department
County ID Number:
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 7 / 1 8 / 2 0 1 9
F
ant: Tina Williams Property Owner: Tina Williams
ss: 776 Williams Address: 776 Williams
CRY: ' Advance CRY: Advance
State2ip: NC 27006 State2ip: NC 27006
Phone#: (336)998-3394 Phone#: (336)998-3394
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
Williams Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 East to Comatzer Rd. tum left to Williams Rd. tum
right to 776 williams on Right
#of Bedrooms: 3
#of People:
*Water Supply: N/A
System Specifications
Minimum Trench Depth: a 4
rSiteification: Provisionally Suitable Inches
Minimum Soil Cover.ystem? OYes QNo 1aInches
esgnow: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 a 7 5 Maximum Soil Cover: a 4 Inches
'System Classification/Description: 'Distribution Type: PUMP TO GRAVITY
TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP
Septic Tank:
_ 1 0 0 0 _ Gallons
*Proposed System: 25%u REDUCTION 1-Piece: OYes QNo
Pump Required: QYes ONo 0May Be Required
Nitrification Field 1 3 0 9
Sq. ft. Pump Tank: 1 0 0 0 Gallons
No. Drain Lines 3 1-Piece: OYes ONo
Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH
Trench Spacing: - 9 81nches O.C. Dosing Volume: _ Gallons
Feet O.C. g
Trench Width: 8Inches
3 Feet Grease Trap: Gallons
Aggregate Depth: inches Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: OI OII OIII OIV
Pagel of 3
CDP File Number 139268- 1 County ID Number:
❑ Open Pump System Sheet
Repair System Required:QYes ONO ONO, but has Available Space
epair System
Trench Spacing: Q Inches O. .
"Site Classification: Provisionally Suitable — 9 Q Feet O.C.
Trench Width: Inches
Design Flow: 3 6 0 _ 3 Feet
Soil Application Rate: 0 - a 7 5 Aggregate Depth: inches
Minimum Trench Depth: a 4 Inches
"System Classification/Description:
TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Minimum Soil Cover. 1 a
Inches
*Proposed System: 25%REDUCTION Maximum Trench Depth: 3 6 Inches
Nitrification Field 1 3 0 9 Sq.ft. Maximum Soil Cover: a 4 Inches
No. Drain Lines 3 `Distribution Type: PUMP TOGRAvITY
Total Trench Length: 3 a 3 ft. Pump Required: QYes ONo OMay Be Required
PreTreatment: 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.
7'
"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.
At.
2(
This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Penni;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 the application fora 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 awning 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 7 / 1 8 / 2 0 1 4
Authorized State Agent: J Malfunction Log OYes
OHand Drawing Olrnport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
• CQNSTRUCTION AUTHORIZATION
Davie County Health Department CDP File Number: 139268 - 1
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 07 / 1 8 / 2 0 1 4
Olnch
Drawing DrawingType: Construction Auth ization Scale: . OBlock = ft,
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IMPROVEMENT PERMIT
"CDP Fite Nurn ber 139268- 1
� e Davie County Health Department
County.
210 Hospital Street
ID Number
P.O. Box 848 Evaluated For NEW
Mocksville NC 27028 Township
Phone: 336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL 7/15/2019
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be issued with this Improvement Permit.
Applicant: Tina Williams Property Owner: Tina Williams
Address: 776 Williams Address: 776 Williams
City: Advance CRY: Advance
State2ip: NC 27006 State2ip: NC 27006
Phone#: (336)998-3394 Phone#: �33�6) 998-3394
Property Location & Site Information
Address/Road #: Subdivision: Phase: Lot:
Williams Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Hwy 64 East to Comatzer Rd. turn left to Williams
#of Bedrooms: 3 Rd. turn right to 776 williams on Right
#of People:
*Water Supply: N/A
S stem S ecificatlons
System
rl—nitial
Classification: Provisionally Suitable
Minimum Trench Depth: a 4 Inches
rolite System? QYes @ No Maximum Trench Depth: 3 6
Inches
Design Flow: 3 6 0 Septic Tank:
1 0 0 0 Gallons
Soil Application Rate:
g a 7 5 1-Piece: QYes QNo
Pump Required: QYes QNo OMay Be Required
'System Classification/Description:
TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP Pump Tank: 1 0 0 0 Gallons
"Proposed System: 25%REDUCTION 1-Piece: QYes t)No
Repair System Required:QYes ONo QNo, but has Available Space
Repair System
"Site Classification: Provisionally Suitable Minimum Trench Depth: a 4 Inches
Soil Application Rate: 0 a 7 5 Maximum Trench Depth: 3 6 Inches
'"System Classification/Description: Pump Required: ()Yes QNo (gMaybe Required
TYPE III B.SYSTEM W/SINGLE EFFLUENT PUMP
"Proposed System: 25%REDUCTION
Pana 1 of 4 y
CPP Fite Numbet 139268 -'l County ID Number:
. *Site Modifications ❑ Open Fill Sheet
No grading or construction activit is allowed in areas designated forsystem and repair without approval of Health Department. t.,
7!
*Permit Conditions
The issuance of this perm it 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.
7!
Site Plan The Improvement Permit shall be valid for 5 years from date of issue with a site plan(means a drawing not necessarily drawn to
scale that shows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
site for the proposed Wastewater system,and the location of water supplies and surfacewaters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
O surveyor,drawn to a scale of one Inch equals no morethan 60 feet,that includes:the specific location of the proposed facility
and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorded with the county register of deeds,a copy
of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article This permit is subject to revocation If the site plan,plat,or intended
use changes(NCGS 130A-335(f)).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-mations,Robert Date of Issue: 1 5 1 x 0 1 4
OValid without Expiration?
Authorized State Agent: 0Create CA?
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Paae 2 of 3
'IMPROVEMENT PERMIT 139268 - 1
Davie County Health Department CDP File Number:
1
210 Hospital Street
P.O.Box 848 County File Number: .
Mocksville NC 27028 Date:
Q Inch
Di-awing Drawing Type: Improvement Permit Scale: OBlock
,y—
QN/A ft.
. _ .
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44
40
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT&ATC /
' Davie County Environmental Health
-RECEIVED P.O.Box 848/210 Hospital Street 1"`r `d
Mocksville,NC 27028 CSG
Iu 1 (336)753-6780/Fax(336)753-1680
Application For: (Site Evaluation/Improvement Permit O Authorization To Construct(ATC) O Both
Type of Application:)44ew System ❑Repair to Existing System ❑Expansion/Modi£cation of Existing System or Facility
***IMPORTANT'**THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. 4,1
APPLICANT INFORMATION
Name to be Billed WlJQ W; I Q rn S Contact Person SCtME f
Billing Address 77& 1A)i 11-*n m S RA Home Phone 33 b'99 8
City/State/ZIP AA1lG#tc2. N C 27000 4 si ess�PhoneCeig 334-7!0–
I
757.3
Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip R '
PROPERTY INFORMATION *Date House/Facility Corners Flagged
NOTE: A survey plat or site plan must accompany this application. Included:O Site Plan ❑Plat(to scale)
_ (Permit is valid for 60 months with site plan,no expiration with complete plat.)
Owner's Name 7-4y Q E. &)"11661^5 Phone Number 336–998339!/
Owner's Address 774 IJAl:ae,s RA City/State/Zip_Qdu�NC 07006
Property Address CityQdua*Jce
Lot Size /$.5 Q C res Tax PIN#S76 g&&71Y92
Subdivision Name(if applicable) Section/Lot# —
Directions To Site: Nwt/ G 4 E. -1-0 COrAJOA-zee Rd 4-wi+ LtfI -1-b Rd 4-um
lb!5U !h 77G' W►11:Qw.s Rd on► RtalJr
If the answer to any of the following questions is`yes",supporting documentation must be attached.
Are there any existing wastewater systems on the site? )Yes ONo
Does the site contain jurisdictional wetlands? 13Yes3(No
Are there any easements or right-of-ways on the site? ❑Yes bio
Is the site subject to approval by another public agency? ❑Yes*0
Will wastewater other than domestic sewage be generated? ❑Yes o
IF RESIDENCE FILL OUT THE BOX BELOW
#People I or #Bedrooms" #Bathrooms Garden Tub/Whirlpool Wes ❑No
Basement: es ONo Basement Plumbing: `❑Yes JgNo
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 consumption)
FOODSERVICE ONLY: #Seats
Type system requested: Woriventional ❑Accepted ❑Innovative ❑Altemative ❑Other
Water Supply Type:XCounty/City Water Or )(New Well ❑Existing Well O Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve?O Yes XNo
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
locat�•�g end flaggjyrg or staking the house/facility location,proposed well location and the location of any other amenities.
ProTpTerty owney/�s�o/r own legal representative signature Site Revisit Charge
Date(s):
Q Client Notification Date:
Date EHS:
Sign given ❑Yes ONo Account#
Revised 11/06 Invoice#
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All data is provided as is without warranty or guarant�df at�kln�chh �t�Ss'�d dr pliFd %%ding but not limited to the implied
cry N. warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County ofU tl
Davie,North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to or arising out
of the use or inability to use the GIS data provided by this website. PCI n}led.J u n 13, 2014
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: Tax PIN/EH#: -
Billed To: (SNW% ISubdivision Info:
R M0'tS '11i�vvls l `
Reference Name: Location/Address:
Proposed Facility: Property Size: g 52C Date Evaluated:
�p 5rt `
i
i
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring_ Pit Cut
FACTORS 1 2 3 4 5 6 7
_Landsca "e position L L 0!1�
Slope % i O Q
HORIZON I DEPTH — 111 1 0 '3
Texture group G C S C_
Consistence Q / 55 5 P fil-
Structure IA14R 11AV C7 Q S k 69
Mineralogy
HORIZON II DEPTH 1 —
Texture groupC
Consistence
Structure S 5$1C1W e
Mineralogy 3;,
HORIZON III DEPTH
Texture groupi
Consistence
Structure i
Mineralogyi
HORIZON IV DEPTH i
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE /
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE T (f '1 .2/7
SITE CLASSIFICATION: / j EVALUATION BY: ez XhAd
LONG-TERM ACCEPTANCE RATE: ` OTHER(S)PRESENT: /
REMARKS:
LEGEND
Lands ape Position i
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 l
CONSISTENCE {
) 41St {
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 l
SC-Single grainM-Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK -Subangular blocky PL-Platy PR-Prismatic
i�4ineraloQv
1:1,2:1,Mixed
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-Lone-term accentance rate-aal/davM2