173 Hickory Tree Road Lot 9Davie County. NC
N
Tax Parr.Pl RPnnrt
Wednesday, January 11, 2017
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:
Building Value:
WARNING: THIS IS NOT A SURVEY
Parcel Information
J701 OA0009
Township:
Fulton
5768223795
Municipality:
CORNATZER
82524910
Census Tract:
37059-804
BISHOP BRIAN ALAN
Voting Precinct:
FULTON
173 HICKORY TREE ROAD
Planning Jurisdiction:
Davie County
MOCKSVILLE
Zoning Class: DAVIE COUNTY R-20
Land Value:
Total Assessed Value:
NC
27028-0000
LOT 9 HICKORY TREE SECTION ONE
0.45
4/2008
007530185
0004
170
Zoning Overlay:
Voluntary Ag. District:
No
Fire Response District:
FORK
Elementary School Zone:
CORNATZER
Middle School Zone:
WILLIAM ELLIS
Soil Types:
GnB2
Flood Zone:
Watershed Overlay:
DAVIE COUNTY
Outbuilding 8r Extra
Freatures Value:
Total Market Value:
O Dt� 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
�O NC or arising out of the use or Inability to use the GIS data provided by this website.
1.
I
OPERATION PERMIT
Davie County Health Department
¢ 210 Hospital Street
P.O. Box 848
1r
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Michelle Bishop
Address: 173 Hickory Tree Rd
City: Mocksville
State/Zip: NC 27028
Phone: (336) 682-0321
P
Address/Road #:
173 Hickory Tree Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
*IP Issued by:
*CA issued by: 2140 - Nations, Robert
*CDP File Number 161515-1
J7 -000 -AO -009
County ID Number:
Evaluated For: REPAIR
Township:
/ property Owner: Michelle Bishop
Address: 173 Hickory Tree Rd
City: Mocksville
State/Zip: NC 27028
I\Phone (336) 682-0321
Subdivision: Hickory Tree
Design Flow: 3 6 0
Soil Application Rate: - 0 a 7 5
Nitrification Field
No. Drain Lines
Total Trench Length
Trench Spacing:
Trench Width:
Aggregate Depth:
Phase: Lot: 9
Directions
Hwy 64 East left on No Creek Rd. Left onto Hickory
Tree
*System Classification/Description:
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
Saprolite System? O Yes Q No
*Distribution Type: GRAVITY - PARALLEL (eq. d -box) Pump Required?
QYes ONo
'Pre -Treatment:
Drain field
1 3 0 9 Sq. ft.
1
3 a 0 ft.
9 Qlnches O.C.
Feet O.C.
3Inches
()Feet
inches
*System Type: EZFLOW EZ 1003T
Installer: Mchlahan Septic
Certification #:
*EH S: 2140 -Nations. Robert
Date: 1 1/ 1 1/ a 0 1 4
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4Inches Approval Status
Maximum Trench Depth: 3 6Inches O Approved 0 Disapproved
Maximum Soil Cover:
2 4 Inches
CDP FileNumber 161515-1
Manufacturer.
Septic Tank
PT:
Lat.
Gallons:
STB:
Date:
/
Riser Sealed ❑
Yes
Gallons:
Yes
einforced Tank: ❑
Yes
1 Piece Tank: ❑
Date:
Approval Status
❑
Approved ❑ Disapproved
Pump Tank
'Filter Brand:
Installer:
❑
Certification #P:
ST Marker:
❑
Yes
❑
No
einforced Tank:
❑
Yes
❑
No
1 Piece Tank:
❑
Yes
❑
NO
Manufacturer.
Septic Tank
PT:
Lat.
Gallons:
Long:
Date:
/
Riser Sealed ❑
Yes
Riser Height: ❑
Yes
einforced Tank: ❑
Yes
1 Piece Tank: ❑
Yes
rA
❑ No
❑ No (Min. 6 in.
❑ No
❑ No
Pipe Size: inch diameter
Pipe Length: feet
'Schedule:
Pressure Rated ❑ Yes ❑ No
approved fittings ❑ Yes ❑ No
County ID Number: J7 -000 -AO -009
Septic Tank
Lat.
Installer:
Long:
,
Installer:
Certification #:
Draw Down:
'EHS:
Inches
Date:
'EHS:
'Chain:
Approval Status
❑
Approved ❑ Disapproved
Pump Tank
Valves Accessible
Installer:
❑
Certification #P:
'EHS:
❑ Yes
Date:
NO
}
Approval Status
❑
Approved ❑ Disapproved
Supply Line
Approval Status
Installer:
❑ Yes
Certification m:
No
'EHS:
Vent Hole
Date:
j
No
Approval Status
❑
Approved ❑ Disapproved
/ Pump Type:
Installer:
Dosing Volume:
-
Gal Certification f,:
Draw Down:
Inches
'EHS:
'Chain:
Date:
Valves Accessible
❑ Yes
❑
No
Flow Adjustment Valve
❑ Yes
❑
NO
Check -valve
❑ Yes
❑
NO
Approval Status
Pvc unions
❑ Yes
❑
No
❑ Approved ❑ Disapproved
Vent Hole
❑ Yes
❑
No
Anti -siphon Hole
0 Yes
❑
No
CbP File Number 161515 -1 County ID Number: J7 -000 -AO -00'3
Electric Ecwirament
NEMA 4X Box or Equivalent
❑ Yes
❑
No
Installer:
Box 12 inches Above Grade
❑
Yes
❑
NO
Certification #:
Box Adj. To Pump Tank
❑
Yes
❑
No
Conduit Sealed
❑
Yes
❑
No
THS:
Pump Manually Operable
❑
Yes
❑
No
*Activation Method:
Date:
Alarm Audible
El
Yes
ElNo
Approval Status
El Approved ❑ Disapproved
Alarm Visible
❑
Yes
ElNo
2140 - Nations. Robert
'Operation Permit completed by:
Authorized State Age Date of Issue: 1 1/ 1 4 1 2 0 1 4
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 II A. sewage septic system.
Rule .1961 requires that a Type TYPE II A. �_— septic system meet the following criteria:
Minimum System Review By The Local Health Department: NIA____--__--�
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator: NIA
Rule .1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract
with a public management entity with 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 entity prior to the
issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the
system owner and certified operator are the same. The contract shall require specific requirements 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.
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached:**
Drawing
• CONSTRUCTION For Office use Only
AUTHORIZATION *CDP File Number 161515-1
Davie County Health Department County ID Number: J7 -000 -AO -009
ur 210 Hospital Street Evaluated For: REPAIR
•4�,. P.O. Box 848Townshi :
P
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 1 0/ a 7/ a 0 1 9
Applicant: Michelle Bishop rAddress:
rty Owner: Michelle Bishop
Address: 173 Hickory Tree Rd 173 Hickory Tree Rd
City: Mocksville City: Mocksville
State/Zip: NC 27028 State/Zip: NC 27028
Phone #: (336) 682-0321 Phone #: (336) 682-0321
Property Location & Site Information
Address/Road #:
173 Hickory Tree Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
Subdivision: Hickory Tree
Phase: Lot: 9
Directions
Hwy 64 East left on No Creek Rd. Left onto Hickory Tree
Pagel of 3
Minimum Trench Depth:
a 4 Inches
Site Classification:
Provisionally suitable
Saprolite System?
OYes QNo
Minimum Soil Cover.
a 1 Inches
Design Flow:
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:
GRAVITY- PARALLEL (eq. d -box)
TYPE II A. CONV SYSTEM (SINGLE-FAMILY
OR 480 GPD OR LESS) Septic Tank:
_ _Gallons
*Proposed System: 25% REDUCTION
1 -Piece:
Oyes ONo
Pump Required: ()Yes
()No ()May Be Required
Nitrification Field
1 3
0
9 Sq. ft. Pump Tank:
Gallons
No. Drain Lines
3
1 -Piece:
OYes ONo
Total Trench Length:
3 a 7
ft
GPM—vs-- ft. TDH
Trench Spacing:9
_
Inches O.C. Dosin Volume:
8FeetO.C. g
Gallons
Trench Width:
3
Inches
8Feet
_
_
Grease Trap:
Gallons
Aggregate Depth:
inches
Pre -Treatment: ONSF OTS -1 OTS -II
Septic Tank Installer Grade Level Required: 01
011 0111 OIV
Pagel of 3
GDP Filb Number 161515 - 1 County ID Number: J7 -000 -AO -009
❑ Open Pump System Sheet
Repair System Required:OYes ONO ONO, but has Available Space
epair System
Trench Spacing: 8Inches O.C.
*Site Classification: — Feet O.C.
Trench Width:Q Inches
Design Flow: o Feet
Soil Application Rate: Aggregate Depth: inches
"System Classification/Description: Minimum Trench Depth: Inches
Minimum Soil Cover.
Inches
Maximum Trench Depth:
}Proposed System: Inches
Maximum Soil Cover:
Nitrification Field
Sq. ft.
No. Drain Lines
Total Trench Length:
ft.
Inches
'Distribution Type:
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. Oct..
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. C.
40
Ensure that outlet of septic tankand distribution box are not blocked and functioning. If they are operating repair by adding designed system below. If the
current system is not sludged and can still be used, use 100 feet of line less that the design.
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 maybe issued at the sametime the Improvement Permit issued (NCGS 13OA-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 maybe 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
Authorized State Agent:
Date of Issue:. 1 0/ a 7/ a 0 1 4
Malfunction Log Oyes
OHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 161515-1
Davie County Health Department CDP File Number:
210 Hospital Street
County File Number: J7 -000 -AO -009
P.O. Box 848
Mocksville NC 27028 Date: 1 0/ 2 7/ 0 0 1 4
Qinch
Drawing Drawing Type: Construction Authorization Scale: , oN/A k
w
c
0,
CP
3
Y
5
4�
Paae 3 of 3
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
NameM;Aele,0S bo Telephone Number ?Z -03 2,1
J
Address --,,,7n OICqtr, r, ,' I 1 ^ A1C 7 5�--
Mailing Address (if different from above)
Email Address:
Subdivision Name .A i (,- A v U l Y'.P I
iusitsimteJOR "W
Date System Installed IQ 1 .7 Name System Installed Under in P, 10
4i�1 �•
Type Facility k Number Bedrooms_ Number People Served
Type Wa er Supply (�n( nj w Specific Problem Occurring �T�r ' To !1�—
d i(71'l ,/1 i AnA
Date Requested Q
THIS IS TO CERTIFY THAT THE INFORMATION PRO
KNOWLEDGE, AND THAT I UNDERSTAND THA A
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date --.97-/ #REHS�
Revisit Charge Date Reason
/(v16'16�
Info Taken By
'I ED IS CORRECT TO THE BEST OF MY
XRESPONSIBLE FOR ALL CHARGES INCURRED
5
DAVIE COUNTY HEALTH DEPARTMENT
`(Se tic Tank) Improvements Permit and Certificate ,of Com leti
(Ground Absorption.Sewage Disposal System - G.S. Chapter 130-A
OWNER OR CONTRACTOR ; `:. �: < :..
��;'l,ti,t_ ��'i��<�� f,°;fDATE
LOCATION 11i,
JV L✓1 Y 1.J1 V1Y. zirwiLi '•'-w ' me LVL 1YV.'
cle 13C)
PERMIT
N°
j 1S.R. NO.
SECTION OR BLOCK NO.
1072
HOUSE MOBILE HOME
U
BUSINESS ❑
ii .
House Trailer., 800 Gal. 400
Sq. Ft:,
NO. BEDROOMS '' NO.
BATHROOMS
Two..Bedroom House. 1800 Gal. 600
Sq. Ft.
GARBAGE DISPOSAL UNIT YES
❑
NO ❑
Three Bedroom House ij900 Gal. 900
Sq. Ft.
AUTO. DISHWASHER YES
❑
NO
Four Bedroom House 1000 Gal. 1200
Sq. Ft.
AUTO. WASH. MACHINE YES
❑
NO ❑
i ► j , `�,� , �,�
SITE SUITABLE. YES
❑
NO
-SIZE OF TANK - gal.
NITRIFICATION FIELD
sq. ft'.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual
❑
Public ®�
h t
IMPROVEMENTS PERMIT BY` ,'�
�,,,, .'1�
INSTALLED BY.
CERTIFICATE OF COMPLETION By Date ?—ate -7 6
W (8/16/73) *.Construction must comply with all other applicable.State,-and local regulations
LOT AREA_�th��
• EI .