123 Brentwood Drive Lot 19CAnty, NC Tax Parcel Report Tuesday, December 6, 2016
9av lg Ali data is provided as Is vdtho d waranly or guarantee of any Idnd eithe,eapressed"Implied Including but not limited to the
Davie County, implied wamantlesormerchantabglryortltheaul
forapartiearuseAllusersofDavieCountfsGISwebsiteshallholdhamdessthe
NC county of oaNe, Norm Carolina, its agents, cmnsuNads, can clota or employeesfrom any and all da ms or es. of action due to
C�UN't; or arising out of the use or Inability to use the GIS data provided by this website.
WARNING: THIS IS NOT A SURVEY
Parcel Information
250
Parcel Number:
D7030B0016
139 % �
Farmington
NCPIN Number:
5862843459
� ,i
Account Number:
8304473
Census Tract:
37059-802
Listed Owner 1:
112
Voting Precinct:
SMITH GROVE
Mailing Address 1:
123 BRENTWOOD DRIVE
O
131 O�
--- -
;
—
O�
ADVANCE
�p
260
y.
509
1'
27006
C
No
Legal Description:
LOT 19 CREEKWOOD ESTATES SECTION TWO
U
SMITH GROVE
123
0.46
Elementary School Zone: PINEBROOK
}
1212014
Middle School Zone:
NORTH DAVIE
517
'.
113
Soil Types:
GnB2
Plat Book:
0005
Flood Zone:
Plat Page:
007
Watershed Overlay:
DAVIE COUNTY
O
OO2
107
O
Land Value:
523 ` ---
Ste'
Total Assessed Value:
'
aUj
9av lg Ali data is provided as Is vdtho d waranly or guarantee of any Idnd eithe,eapressed"Implied Including but not limited to the
Davie County, implied wamantlesormerchantabglryortltheaul
forapartiearuseAllusersofDavieCountfsGISwebsiteshallholdhamdessthe
NC county of oaNe, Norm Carolina, its agents, cmnsuNads, can clota or employeesfrom any and all da ms or es. of action due to
C�UN't; or arising out of the use or Inability to use the GIS data provided by this website.
WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number:
D7030B0016
Township:
Farmington
NCPIN Number:
5862843459
Municipality:
Account Number:
8304473
Census Tract:
37059-802
Listed Owner 1:
MCLEMORE MELISSA J
Voting Precinct:
SMITH GROVE
Mailing Address 1:
123 BRENTWOOD DRIVE
Planning Jurisdiction:
Davie County
City:
ADVANCE
Zoning Class: DAVIE COUNTY R-20
State:
NC
Zoning Overlay: DAVIE COUNTY QD
Zip Code:
27006
Voluntary Ag. District:
No
Legal Description:
LOT 19 CREEKWOOD ESTATES SECTION TWO
Fire Response District:
SMITH GROVE
Assessed Acreage:
0.46
Elementary School Zone: PINEBROOK
Deed Date:
1212014
Middle School Zone:
NORTH DAVIE
Deed Book / Page:
009750745
Soil Types:
GnB2
Plat Book:
0005
Flood Zone:
Plat Page:
007
Watershed Overlay:
DAVIE COUNTY
Outbuilding & Extra
Building Value:
Freatures Value:
Land Value:
Total Market Value:
Total Assessed Value:
9av lg Ali data is provided as Is vdtho d waranly or guarantee of any Idnd eithe,eapressed"Implied Including but not limited to the
Davie County, implied wamantlesormerchantabglryortltheaul
forapartiearuseAllusersofDavieCountfsGISwebsiteshallholdhamdessthe
NC county of oaNe, Norm Carolina, its agents, cmnsuNads, can clota or employeesfrom any and all da ms or es. of action due to
C�UN't; or arising out of the use or Inability to use the GIS data provided by this website.
HEALTH DEPARTMENT RELEA5t
vz
� 0
Davie County Health Department
210 Hospital Street
f
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Stephen Peters
Address: 736 LA Vale Drive
City: Clemmons
State/Zip: NC 27012
Phone #: (336) 712-0430
'CDP File Number 161856 - 1
D7 -030 -BO -016
County ID Number:
?valuated For. REPAIR
PERMIT VALID 1 1/ 1 3 1 a 0 1 9
UNTIL:
4roperty Owner: Stephen Peters
Address:- 736 LA Vale Drive
City: Clemmons
State[Zip: NC 27012
hone#: (336)712-0430
Property Location & Site Information
Address 123 Brentwood Drive Subdivision: Creekwood
Road Clemmons NC 27012
Township:
Directions
1-40 east to Hwy 801 go left north, left on Creekwood, last right
Brentwood home on left
'Structure:
SINGLE FAMILY
4 of Bedrooms: 3
'Water Supply: PUBLIC
Basement: n Yes ❑ No
'Proposed Improvement:
R of People:
Phase: Lot: 19
Type of Business'
Total sq. Footage:
pump old tank out, crush, and replace with a new 1000 gallon tank
No. Of Employees:
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? Oyes ONo
Applicant/Legal Reps. Signature;
'Date: / /
"Issued By: 2140 -Nations, Robert Tate of Issue: 1 1/ 1 3/ 2 0 1 4
Authorized State Agent: � V (/L.
**Site Plan/Drawing attached.**
b Hand Drawing Olmport Drawing
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
33 t
� y P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
*CDP File Number 161856-1
D7-030-64016
County ID Number:
Evaluated For: REPAIR
�ownship:
Applicant: Stephen Peters
Property Owner: Stephen Peters
36 LA Vale Drive
Address: 736 LA Vale Drive
Clemmons
LPhone#:
City: Clemmons
NC
27012
State/Zip: NC 27012
336) 712-0430
Phone #: (336) 712-0430
Property
Location & Site Information
Address/Road#:
Subdivision:
Creekwood Phase: Lot: 19
123 Brentwood Drive
Clemmons NC 27012
Directions
Structure: SINGLE FAMILY
1-40 east to Hwy 801 go left north, left on Creekwood,
last right Brentwood home on left
# of Bedrooms: 3
# of People:
'Water Supply: PUBLIC
*IP Issued by:
*System Classification/Description:
*CA issued by:
SaproliteSystem? QYes QNo
Design Flow:
Pump Required?
'Distribution Type: QYes ®No
Soil Application Rate:
*pre -Treatment:
Drain field
Nitrification Field
Sq_ ft. *System Type:
No. Drain Lines
Installer:
Total Trench Length:
ft.
Certification #:
Trench Spacing: —8Feet
Inches O.C.
O.C. *EHS:
Trench Width: —
Inches
Feet J J
Date:
Aggregate Depth: inches
Minimum Trench Depth:
Inches
Minimum Soil Cover.
Inches
Approval Status
Maximum Trench Depth:
0 Approved O Disapproved
Inches
Maximum Soil Cover:
Inches
CDP File Number 161856 -1
Manufacturer. shoat
STB:
760
❑
No (Min.6 in.)
Gallons:
1000
❑
No
Date:
07/
18
i a 0 1 4
'Filter Brand:
No
Anti -siphon Hole
❑ Yes
STMarker:
❑ Yes
El
No
nforced Tank:
❑ Yes
F±1
No
1 Piece Tank:
❑ Yes
El
No
County ID Number: D7.030-130-0ts
Lat.
Long:
Installer: P and M septic
Certification #:
'EHS: 2140 - mations, Robert
Date: 1 1 / 1 4 ( 2 0 1 4
Approval Status
F gi Approved ❑ Disapproved
Pump Tank
Manufacturer. Installer:
PT: Certification #:
Gallons: 'EHS:
Date:
Riser Sealed ❑ Yes
RiserHeight: ❑ Yes
nforced Tank: ❑ Yes
1 Piece Tank: ❑ Yes
❑
No
❑
No (Min.6 in.)
❑
No
❑
No
Pipe Size: inch diameter
Pipe Length: feet
'Schedule:
Pressure Rated ❑ Yes ❑ No
,pproved fittings ❑ Yes ❑ No
Date:
Approval Status
❑ Approved ❑ Disapproved
Installer:
Certification #:
'EHS:
Date:
Approval Status
❑ Approved ❑ Disapproved
Pump Type: Installer:
Dosing Volume: - Gal Certification #:
Draw Down: Inches 'EHS:
'Chain:
Date:
Valves Accessible ❑ Yes ❑ No
w Adjustment Valve ❑ Yes ❑ No
Check -valve
Yes
El
No
Approval Status
PVC unions
❑ Yes
O
No
❑ ApprovedO Disapproved
VentHole
❑ Yes
❑
No
Anti -siphon Hole
❑ Yes
❑
No
CDP File Number 161856 -1
NEMA 4X Box or Equivalent
❑ Yes
❑
No
Box 12 inches Above Grade
❑
Yes
❑
No
Box Adj. To Pump Tank
❑
Yes
❑
No
Conduit Sealed
❑
Yes
❑
No
Pump Manually Operable
❑
Yes
❑
No
`Activation Method:
Alarm Audible ❑ Yes ❑ No
Alarm Visible ❑ Yes ❑ No
2140 - Nations, Robert
`Operation Permit completed by:
Authorized State
County ID Number: W-030-130-016
Installer:
Certification #:
'EHS:
Date: / /
Approval Status
❑ Approved[] Disapproved
Date of Issue: 1 1 / 1 4 /.1 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 sewage septic system.
Rule .1961 requires that a Type
septic system meet the following criteria:
Minimum System Review By The Local Health Department:
Management Entity:
Minimum System Inspection/Maintenance Frequency By Certified Operator:
Reporting Frequency By Certified Operator:
Rule .1961 requires that a Type IV and V septic systems designed for a homelbusiness owner must maintain a valid contract
with a public management entitywith 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 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.**
DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE RE UEST
APPLICATION IP/ATC OSWW REPAIR
j• � k s
�efletL � 0%iephorneNumb 0
Name e
r )
Address
Mailing Address (if different from above)
(P•i (%Gi L fig /�i JQ/
Email Address:
Subdivision Name
Lot #
D' do —WW1' 5?0l
CIO -rUfAf OAI 00. O as
DO o
LLe
Date System Instal d l q Z q
Name System Installed Under
Type Facility JV9,56
Number Bedrooms 3 Number People Served
Type Water Supply
Specific Problem Occurring
Date Requested
Info Taken By '
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT TO THE BEST OF MY
KNOWLEDGE, AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date
REHS
Revisit Charge Date
Reason
Revised 2-2011
DAVIE COUNTY HEALTH DEPARTMENT
ti IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
-NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article tic
Sewage Treatment and Disposal Flutes (10 NCAC t0A .1934..1968) Permit Number
Name'-.-'=4.tis .L.n'; :,�,.i
—Date 1Y `t. •� ::j� 322
Location
Subdivtslo6 Name
"Jr10-;0D7r _'i i Lot No. ,! t_ Sec. or Block No.
Lot Size
House -- "Moblle Home� Business Speculation
No. Bedrooms '- 9
No. Baths -7— No, In Family 4-1 '
Garbage Disposal
Auto Dish Washer
YES u NO p. Specifications for System: V,,W7/
YES j( NO v
❑
Auto Wash Machine//l�
YES gr NO Cl
Type Water Supply
Ax pP'^r' f811J NE ..• r : r�r. Frits 7
'This permit Void if sewage system described below Is not installed within 36 months from date of Issue,
,1
1
? � 1
J -
1
4 r
3
Improvements permit by����
'Contact a representative of the Davie Comfy Health Department for final inspectioff of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number. 704-694-5985.
r
Final Installation Diagram: System Installed
fAcC
291 IlJ'Ins
Certificate of Completlon Date12
'The signing of this certificate shall Indicate that the system descrtifed 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.
CI
s
• MENT
..... OlZ G /�U�tC.
proeineotS;'Pemiit
and Cezlificate of 6mpletion
ti-�;.bsgpoii.Sewage pisposal :System 0..5.. Chapter 130 -Article 13C)
'bR. tCON1ZtLiCTO&'•"� 1"4+er,: - rd%. DATE "o ^I G, PERMIT
30
'.'LO.EATION - ' �,•` la 3�eu��vda� ��'.- - N 985
r /I S.R. NO.
SUBDIVISION NAME LOT N0. +��� SECTION OR BLOCK NO. .y
nuu5WA u mvDibB nva
u aUOJ.14Lbz. U,
-' - .:- :.--;{... :,•
House Tra]er •y 800 Gal.
400
Sq. Ft.
NO. BEDROOMS , -7 NO.
BATHROOMS
Two.'Bedro6¢i'1i4us.e; 800 Gal.
600
Sq. Ft.
GARBAGE DISPOSAL UNIT YES,
NO ❑
Three.B'edioom." House 900 Gal.
900
Sq. Ft.
AUTO. DISHWASHER YES
Q NO ❑
Four Bedroom House 1000 Gal.
1200
$q. Ft.
AUTO. WASH. MACHINE YES
O NO" ❑
,�l � - � ��� � �.,,f
�
i :
SITE SUITABLE YES
ED NO ❑
'
SIZE OF TANK fn??,rr" gal.
'
n • �
mv ' 1A
NITRIFICATION FIELD
k -it r1.n sj.
DEPTH OF STONE IN LINESz
r k
Lir red,.3ie �'�.. Q6Cl 'Lel/L:
WATER SUPPLY: Individual
Q Public a
IMPROVEMENTS PERMIT BY i
.;a.,.,• �.�...___
INSTALLED -BY
CERTIFICATE OF COMPLETION By Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA D, U t t -
3
S'"
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance !i itli' G,&: of North Carolina Chapter 130 Article 13c
Sewage Tre tment and Disposal Rules (10 NCAC.10A .1934-.19/68) c Permit Number
Name Li z Cant - Date U22
Location " M
aS 0Sre,0J -1-(W-0
Subd
Lot Size House ✓ M bile Home
No. Bedrooms No. Baths No. in Family.
Garbage Disposal YES {� �NO ❑
Auto Dish Washer YES [NO fl
Auto Wash Machine YES p' NO p
Type Water Supply
Sec. or Block No
Business Speculation
Specifications for System:
%50`X -3X/9 /57aD✓£ -�
NCS C /A/L
L
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
*Contact a representative of the Davie County Health Department for final inspectioK 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:
Installed
Certificate of CompletionDate I2'
"The signing of this certificate shall indicate that the system descred above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way betaken as a guarantee that the system will function
satisfactorily for any given" -period of time.
DAVIE COUNTY HEALTH DEPARTMENT
u IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ,
1, *. NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Tre tment and Disposal Rules (10 NCAC 10A .19�3/4-.1968) Permit Number
Name'
aftr,l£ cant Date �/ — �;� 112
Location
Subdivision Name:Z7 Lot No. J% Sec. or Block No.
Lot Size House !n�Kiobile Home Business Speculation
No. Bedrooms — No. Baths_ No. in Family LG
Garbage Disposal YES E�',NO ❑ Specifications for System: _t,17t1,2
Auto Dish Washer YES NO E]
Auto Wash Machine YES NO p
Type Water Supply Oa s7 NE v c 1tvf�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
2
J
�U
3
Improvements permit
*Contact a representative of the Davie County Health Department for final
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number:'.
Final Installation Diagram: .
Installed
DAVIE CDUNTY HEALTH DEPARTMENT
(Septic Tank) Improvements Permit and Certificate of. Completion
(Ground Absorption Sewage Disposal System - G.S. Chapter 130 -Article 13C)
OWNER OR CONTRACTOR �1;r (� (�: ti's _ DATE .S - -7�_. PERMIT
LOCATION Ia3 �GZP.N{wood N° 985
S.R. NO.
SUBDIVISION NAME : eft n'1 -.per' R -LOT NO. I Q SECTION OR BLOCK NO. N'
—1 -7--- -C
HOUSE . p MOBILE HOME ❑ BUSINESS ❑
t
NO. BEDROOMS, - NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES C NO ❑
AUTO. DISHWASHER YES NO ❑
AUTO. WASH. MACHINE YES ❑ NO ❑
SITE SUITABLE -' YES n NO _ ❑
SIZE OF TANK gal:
NITRIFICATION FIELD n,r� sq. ft. ,
DEPTH OF STONE IN LINES: / ^• '/ .
WATER SUPPLY: Individual ❑' Public ❑
1L. _
IMPROVEMENTS PERMIT BY .4"1, e l
House Trailer 800 Gal. 400 Sq. Ft.
Two Bedroom House, 800 Gal. 600 Sq. Ft.
Three Bedroom House 900 Gal. 900 Sq. Ft.
Four Bedroom House 1000 Gala 1200 Sq. Ft.
INSTALLED ^BY
CERTIFICATE OF COMPLETION
By Date
(8/16/73) *Construction must comply with all other applicable State and local regulations
LOT AREA
9
Q)
i
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Y"' J
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Al
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U
DAME COUNTY HEALTH DEPARTMENT
'~ (Septic Tank) Improvements Permit and Certificate of Completion
(Ground Absorption Sewage Disposal System G.S. Chapter 130 -Article 13C) .
OWNER OR CONTRACTOR (�y�vyc �y j �� DATE PERMIT
p
LOCATION 1� O 985
5
S.R. NO.
SUBDIVISION NAME°Z LOT NO. T� SECTION OR BLOCK NO. o_
- r
HOUSE MOBILE HOME
L3 BUSINESS
NO. B ROOMS _ NO.
BATHROOMS
GARBAGE DISPOSAL UNIT YES.
NO ❑
AUTO. DISHWASHER YES
NO ❑
AUTO. WASH. MACHINE_ YES
NO ❑
SITE SUITABLE YES
NO ❑
SIZE OF TANK ga i
NITRIFICATION FIELD
.O O sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual
Public ❑
IMPROVEMENTS PERMIT BY
CERTIFICATE OF COMPLETION By
(8/16/73) *Construction must comply wi
LOT AREA
U
House Trailer" 800 Gal. 400 Sq. Ft.
Two Bedroom House 800 Gal. 600 Sq. Ft.
Three Bedroom House 900 Gal. 900 Sq. Ft.
Four Bedroom House 1000 Gal. 1200 Sq. Ft.
fect?tD.� 3a6,
3A
r -
a �iNeS.lbo`1<3`X 1�ajC
INSTALLED BY i
Date
h all other applicable State and local regulations