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434 Cornatzer Road Section 2 Lot 2Davie County, NC , I Tax Parcel Report Tuesday. January 17. 2017 WARNING: THIS 1S NOTA SURVEY Parcel Information Parcel Number: 1614OA0048 Township: Shady Grove NCPIN Number: 5758730387 Municipality: 1\ Account Number: 8306823 Census Tract: 37059-804 Listed Owner 1: THURLOW BRIAN A Voting Precinct: WEST SHADY GROVE Mailing Address 1: 434 CORNATZER ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-20 State: NC Zoning Overlay: Zip Code: 27028 Voluntary Ag. District: No Legal Description: LOT 2 HICKORY HILL SECTION 2 Fire Response District: CORNATZER - DULIN Assessed Acreage: 0.74 Elementary School Zone: CORNATZER Deed Date: 9/2016 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 010280441 Soil Types: GnB2,GnC2,GaD,WATER Plat Book: 0005 Flood Zone: Plat Page: 026 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding & Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: Davie County, data is prodded as Is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the Implied warranties of merchantability or fitness for a particular use. All users of Dade County's GIS webshe shall hold harmless the F--a7 �7All �rCounty C of Dade, North Carolina, its agents, consul ants, contractors or employees from any and all claims or causes of action due to the Inability to the GIS data by this 1\ or arising out of use or use prodded website. Davie County Health Department 'Geis` Environmental Health Section ;i,... P.O. Box 848'' 210 Hospital Street P s fi Q Courier #: 09-40-06 t Q :1 Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: I V ^ Phone Number ome Mailing Address: Email Address: Detailed Directions To Property Address; (W'ork) Please Fill In The Following Int rmation About The%EXISTING Facility: Name System Installed Under: alp 05 6 Type Of Facility: Date System Installed (Month/Date/Year): �� Number Of Bedrooms: Number Of People: `~ Is The Facility Currently Vacant Ye(Lo-,-)If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Follow' g Information About The NEW Facility: Type Of Facility: r N Number Of Bedrooms: Number of People Pool Size: Garage Size: Other: Requested By: ate Requested: % ��- /y For Environmental Health Office Use Only Disapproved Comments: �/1 41 Environmental Health Specialist Date: /d - S *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:$ Date: Paid By: Received By: Account #: Invoice #: OPERATION PERMIT Davie County Health Department rt 210 Hospital Street 1! P.O. Box 848 Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 Applicant: Andrew Zalewski Address: PO Box 381 City: Advance State/Zip: NC 27028 Phone #: (910) 409-0579 Address/Road #: 434 Cornatzer Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: *Water Supply: PUBLIC *IP Issued by: *CA issued by: 2140 - Nations, Robert /,Property Owner: Andrew Zalewski Address: PO Box 381 City: Advance State/Zip: NC 27028 Ph one #: (910) 409-0579 Subdivision: Hickory Hill 2 Phase: Lot: 2 Design Flow: 3 6 0 Soil Application Rate: 0 0 7 5 Nitrification Field No. Drain Lines Total Trench Length: Trench Spacing: Trench Width: Aggregate Depth: Directions Hwy 64 East left on Cornatzer Rd. property on right 1 3 0 9 Sq. ft. *System Classification/Description: TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Saprolite System? O Yes (9) No *Distribution Type: GRAVITY -SERIAL Pump Re wired? O Yes No *Pre -Treatment: 327 ft. 9 Q Inches O.C. Weet 0. C. 3 Inches Feet inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover: 0 4 Inches Maximum Trench Depth: 3 6 Inches Maximum Soil Cover: 0 4 Inches Page 1 of 4 *System Type: INFILTRATOR QUICK 4 STANDARD Installer: Shannon Henderson Certification #: 1091 *EHS: 2140 - Nations, Robert Date: 1 1/ 0 5/ 0 0 14 CDP File Number 158687 - 1 Manufacturer: Dosing Volume: shoat Pump Tank Draw Down: STB: 760 *Chain: Gallons: 1000 ❑ Yes Date: 0 6/ a a/ a 0 1 4 *Filter Brand: POLYLOK Dual PL -122 With Pipe Adapter ST Marker: ❑ Yes ® No Reinforced Tank: ❑Yes ® NO 1 Piece Tank: ❑Yes ®NO Countv ID Number: Lat. Long: Installer: 1091 Certification #: *EHS: 2140 - Nations, Robert Date: 1 1/ a 5/ a 0 1 4 / Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ NO Approved fittings ❑ Yes ❑ NO / Pump Type: Dosing Volume: Pump Tank Draw Down: *Chain: Valves Accessible ❑ Yes Manufacturer: ❑ Yes Check -valve ❑ Installer: PVC Unions ❑ PT: Vent Hole ❑ Yes Anti -siphon Hole Certification #: Yes Gallons: *EHS: Date: / / Date: Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes ❑ No (Min. 6 in.) „ Approval Status inforced Tank: El Yes El No fie" Approved❑ Disapproved 1 Piece Tank: ❑ Yes ❑ No a, / Pipe Size: inch diameter Pipe Length: feet *Schedule: Pressure Rated ❑ Yes ❑ NO Approved fittings ❑ Yes ❑ NO / Pump Type: Dosing Volume: Draw Down: *Chain: Valves Accessible ❑ Yes Flow Adjustment Valve ❑ Yes Check -valve ❑ Yes PVC Unions ❑ Yes Vent Hole ❑ Yes Anti -siphon Hole ❑ Yes Supply Line Installer: Certification #: *EHS: Date: / Installer: Gal Certification #: Inches *EHS: ❑ No ❑ No ❑ No ❑ No ❑ No ❑ No Page 2 of 4 Date: / CDP File Number 158687-1 County ID Number: Electric Eauioment 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 *EHS: Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Date: Apoval;Status Alarm Audible ElYes El No Approved ❑ 'Disapproved Alarm Visible El Yes El No 2140 - Nations, Robert *Operation Permit completed by: Authorized State Agent: Date of Issue: 1 1/ a 5 / a 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.1 900 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: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A 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. ® Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3 of 4 OPERATION PERMIT Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC Drawing Drawing Type: Operation Permit CDP File Number: 158687 - 1 County File Number: 27028 Date: / / 0 Inch Scale: , , 0 Block 0 N/A Page 4 of 4 P1 P2 P3 OPERATION PERMIT Davie County Health Department 210 Hospital Street CDP File Number: P.O. Box 848 Mocksville NC 27028 County File Number: Date:. . / Click below to import an image from an external location: Drawing Type: Operation Permit Page 4 of 4 P1 P2 P3 Drain Field: System Final Inspection Log: Characters Remaning 4000 Septic Tank: Pump Tank: Supply Line: Pump Requirements: Electrical Equipment: P1 P2 P3 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 Characters Remaining 4000 CONSTRUCTION AUTHORIZATION r Davie County Health Department 4� rsy 210 Hospital Street P.O. Box 848 For Office Use Only *CDP File Number 158687-1 County ID Number: Evaluated For: NEW `Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 1 0/ 0 9/ a 0 1 9 Applicant: Andrew Zalewski Property Owner. Andrew Zalewski Address: PO Box 381 Address: PO Box 381 City: Advance State/Zip: NC Phone #: (910) 409-0579 P rc Address/Road #: 434 Cornatzer Road Mocksville NC 27028 Structure: SINGLE FAMILY # of Bedrooms: 3 # of People: "Water Supply: PUBLIC City: Advance 27028 State/Zip: NC 27028 Phone #: (910) 409-0579 C•Ii] Subdivision: Hickory Hill 2 Phase: Lot: 2 Directions Hwy 64 East left on Cornatzer Rd. property on right Pagel of 3 Minimum Trench Depth: a 4 Inches Site Classification: Provisionally Suitable Saprolite System? QYes ONo Minimum Soil Cover. 1 a 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 -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: QYes QNo Pump Required: QYes QNo OMay Be Required Nitrification Field 1 3 0 9 Sq. ft. Pump Tank: Gallons No. Drain Lines 4 1 -Piece: QYes ONo Total Trench Length: 3 a 7 ft GPM—vs— ft. TDH Trench Spacing:9 _ Inches O.C. Dosing Volume: Feet O.C. g _ Gallons Trench Width: 3 81nehes Feet _ . Grease Trap: Gallons Aggregate Depth: inches Pre -Treatment: ONSF OTS -1 OTS -11 Septic Tank Installer Grade Level Required: 01 011 OIII OIV / Pagel of 3 CDP File Number .158687 - 1 County ID Number: ❑ Open Pump System Sheet Repairsysiem itequirea:v icbyrvuyrvu, uui 11dsrlvdndurc oNdcr '-- Trench Spacing: OInches 0. 9 *Site Classification: Provisionally Suitable — 3 Feet O.C. Design Flow: Trench Width: Inches 3 Feet 3 6 0 _ �. Aggregate Depth: Soil Application Rate: 0 inches Minimum Trench Depth: a 4 "System Classification/Description: Inches TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. 1 a Inches Maximum Trench Depth: 3 6%REDUCTION *Proposed System: 25 Inches Maximum Soil Cover: a 4 Nitrification Field 1 3 0 9 Inches Sq. ft. No. Drain Lines *Distribution Type: GRAVITY -SERIAL 4 Total Trench Length: 3 a 7 Pump Required: Oyes ONo OMayBe Required ft \, Pre -Treatment: 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 by the Health Department in no way guarantees the issuance of other pennits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements.C. 2 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 130A-336(b)j 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 Date of Issue:. 1 0/ 0 9/ a 0 1 4 Authorized State Agent: Malfunction Log OYes OHand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital Street P.O. Box 848 Mocksville NC 27028 Drawing Drawing Type: Construction Authorization CDP File Number: 158687 - 1 County File Number: Date: 10/09/2014 Olnch Scale: OBlock ON/A tA. Y t 6 i t' 0 �CL L� `0 1O.L (r. I c-, t 3 3ok C C, Cd �' w f 2 -�✓' d �` C� Paoe 3 of 3 APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC Davie County Environmental Health_-- P.O. Box 848/210 Hospital Street Mocksville, NC 27028 ReQe1 `'`�''y]• t n {336)753-6780/Fax (336) 753-1680"fib . p AIF ite Evaluation/Improvement Permit ❑ Authorization To Construct(ATC) oth o kation: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility �. ***1J&fflORTAN7*** THIS APPLICAT10N CAAWOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. I WN Name to be Billed a /k0 R C- W Z 4 L Lr ---W -3K ( Contact Person Billing Address P c> r o 7L 3 g l Home Phone City/State/ZIP A 1) y A nc r h a 7- 7 00 usiness Phone Name on Permit/ATC if Different than Above Mailing Address NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Name A rYa iZ 0-' w 'Z 4 L r_ c" 9 K r Phone Number Cf/D • 4 o9 -05' 7c, Owner's Address P r5 13 n X 3 R I City/State/Zip A D U ►i N c �_= n, e -x -7 o& L' Property Address 43 y Q o e n 4 7-.-, r'Q R City—W D 7t ✓ r C C Lot Size t7, i3 3 A a g r' Tax PIN# Subdivision Name(if applicable) FJ le go i, y HiCb Z Section/Low-2. Directions To Site: Ort; y T o C o 2 n a -t-1! s P 4 rf, z a x -*A wr . L .n, ov O /X !Z I q 4 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 ZW6 Does the site contain jurisdictional wetlands? 11YesJ2N—o Are there any easements or right-of-ways on the site? .BYes ❑No Is the site subject to approval by another public agency? ❑Yes.&No Will wastewater other than domestic sewage be venerated? ❑Yes2llfo IF RESIDENCE FILL OUT THE BOX BELOW # People 2 # Bedrooms :— # Bathrooms �_ Garden Tub/Whirlpool ❑ Yes o Basement: ❑Yes o Basement Plumbing: ❑Yes J -NW 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: er nventional ❑Accepted ❑Innovative ❑Altemative ❑Other Water Supply Type: County/City Water ❑ New Well ❑Existing Well 0 Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes If yes, what type? ,�o This is to certify that the information provided o rs application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted ' application is falsified or changed I hereby grant right of entry to the Authorized Represent, ' of the Davie County I apartment to conduct necessary inspections to determine compliance with applicable laws an s. I understand that r ponsible for the proper identification and labeling of property lines and comers and j locati a gging o staking use/facility location, proposed well location and the location of any other amenities. Pro eowner'sowner'oro er's legal representative signature Site Revisit Charge Date(s): Client Notification Date: Date EHS: Sign given ❑Yes ❑No Revised 11/06 Account #v Invoice # Lot 8 Hickory Hili Sectlon2 \ PB5Pg26 \ Notes: Areas computed by coordinate method unless noted All distances are horizontal ground, US Survey foot, unless noted This map is subject to any facts that may be disclosed by a full and accurate title search This map is subject to any easements, agreements, or rights-of-wa of record prior to the date of this map,which were not visible at the time of my inspection. Unable to locate published horizontal control within 2000 feet of this site Legend: EIR=Exisiting Iron Rod EIP=Existing Iron Pipe SIR=Set Iron Rod SIP=Set Iron Pipe X = Calculated Point UP=Ublity Pole =Property lines surveyed - — - =Lines plotted from deeds or plats - — - -Tie lines - - =Water course — -- =Right -of -Way line Lot 9 Hickory Hill Section2 PB5Pg26 N Lake Edge of Water N �O 718" EIP 1.2' Deep This being Lot 2 of Hickory Hill Section 2 as per Plat Book 5 Page 26 434 Comatzer Road wp 0.83 acre by plat TO Q z Deed Reference: DB 858 Pg 064 A p Parcel Number. 1614AO048 PIN:5758730387 z , — - Z2 • y — — � 6, — -- T --.1.1—x' 1o.i —r Daniel E. and Tammera L Mansir�yy F - TVA€ DB 946 Pg 639 X L} (' 22 1 __. Lot 3 Hickory Hill Section2 I PB5Pg26 N > N I \ fo Po C H I sy` r , > — N34°06'30=459�to' l'n! r _ _ _ r I Y/ S35'1T24"E \ 66A2'toF-- _ •-----'•- - —- ounGranite Monument \ Septic Easement as per DB 156 Pg 330 Sharon Kubisch DB 786 Pg 118 Lot 1 Hickory Hill Secbon2 PB5Pg26 Existing Right-of-Wa Ede pavement - N 35'20'30^ W � 100.00• _ — "—__-- -------------- --�—N'4360"ty --`----•---- > 16.00, Cornatzer Road SR 1616 - 21' Paved 1 - -- - - _ 60' Right -of -Way as per plat > r--- - - - -- UP I certity brat this ma,) was drawn under my supervision from an acival survv,, made under my supervision from Deed Book e5d Paye 84 ;r other reference sources as shown; that the boundaries not surveyed are indicated as drawn froin sources as st,owr that the ratio of precision is 1:10,000; and thw uNs map meets the requirements of The Standards of Practice for Land Surveying in North Carolina (21 NCAC 56.1600). This 2 d Sep m , Qt\ i ey H. PLS 420 surveyed By: 1 4utry-Abemathy, P.P- C-2341 [t\ 601 Skylark Road sfafftown, N.C. 27040 �t Survey For - Andrew Zalewski and wife Nancy C. Zalewski Fulton Township - Davie County, NC Scale 1 Inch = 30 feet --I - ---•, 30 o so so Date of Survey: September 19, 2014 Project ID: DVE14106 APPLICANT INFORMATION ite Well Boring DAVIE COUNTY HEALTH DEPARTM4NT Environmental Health Section Soil/ Site Evaluation Community Pit PROPERTY �1&ko(j ' INFORMATION N1,11 rz i I blic j Cut Arid r�,w -zA ago 5� , Water Supply: �� On- Evaluation By: Auger FACTORS 1 2 3 5 6 7 Landscape position Slope % 1 j HORIZON I DEPTH d c{ 1 j Texture group { C✓ j Consistence r S h I1 Structure j 1 CBly 1 i i Mineralogy A HORIZON II DEPTH # Texture group Consistence Structure i Mineralogy! ! HORIZON III DEPTH ! j Texture group Consistence ' Structure Mineralogy{ l HORIZON IV DEPTH I I Texture group Consistence Structure i 1 Mineralogy{ 1 SOIL WETNESS { t I RESTRICTIVE HORIZON I I SAPROLITE I I I CLASSIFICATION LONG-TERM ACCEPTANCE RATE d 7M1 SITE CLASSIFICATION: _ EVALUATI NB � LONG-TERM REMARKS: TANCE RATE: • d ' U"rHrx(5) FF FbhN 1'. LEGEND Landscape position R - Ridge S - Shoulder j L - Linear slope FS Foot slope N - Nose slope', CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H!_ Head slop Texture S - Sand LS - Loamy sand,, SL - Sandy loam L - Loam SI - Silt SICL - Silty clay loam SII - Silty loam CL - Clay loam SCL - Sandy clay loam SC - Sandy clay SIC - Silty clay C - Clay CONSISTENCE Moist VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm NS - Non sticky SS. - Slightly sticky S -Sticky VS -Very Sticky I NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic Structure SC - Single grain M - Mas,sive CR - Crumb GR - Granular ABK - Ang; lar blocky SBK - Subangular blocky L - Platy PR - Prismatic l Mineralog V 1:1, 2:1, Mixed Notes. ` Horizon depth - In inches i I 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 c Classification - S(suitable), PS(provisionally suitable), U(unsuitable) TTA" T -----__�__ 2 or less