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386 Boxwood Church RdDavie County, NC j,. �._., : I l:,. Tax Parcel Report Wednesday, October 12, 2016 � ,/l`� /'�, �' � �- J� . 4 +� t! j� �/{` � ✓/ , I f .. / �SSl l' ✓ ti ` S �� 4. , ✓ . .... _ I , � .t M y � �,� �J' �,: . .36U ' �:_'� ,��;�,� �' 1' ' x1 Sr '�� . 7 �l ! \� � ,� t �;,, i . � ✓'`. , ^:�. � . . . �.,r- .r,- � % ��`°�"� - � �� ' __ . z� �, ��- ,-� ., `� �� 1 °-;i � �� 9 w . ,�- , 'E , �d N t 1 �°3 1 � 1 � ,''� �'u' � f � �' E i ' �� L + € f % _ � � � �`f � k . - 1. J �`t ,� � �ti l� �� i € - ,, � �' �' ,_� !� 4 r ,.� �� ,, � jF� WARNING: THIS IS NOT A SURV�Y _ __ __ __ _ _ _ . Parcel Information Parcel Number: N60000007106 Township: Jerusalem NCPIN Number: 5754387414 Municipality: Account Number: 43551000 Census Tract: 37059-807 Listed Owner 1: KOPETZKY THOMAS HANS Voting Precinct: JERUSALEM Mailing Address 1: 386 BOXWOOD CHURCH ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-20 State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag. District: No Legal Description: 1.088 AC BOXWOOD CHURCH Fire Response District: JERUSALEM Assessed Acreage: 0.91 Elementary School Zone: COOLEEMEE Deed Date: 9/1998 Middle School Zone: SOUTH DAVIE Deed Book / Page: 002050906 Soil Types: Pc62,PcC2 Plat Book: Flood Zone: Plat Page: Watershed Overlay: DAVIE COUNTY Building Value: 78490.00 Outbuilding 8� Extra Freatures Value: Land Value: 18950.00 Total Market Value: Total Assessed Value: °�^�°'F Davie County, �ot��y�c'� NC 98800.00 1360.00 98800.00 411 data Is provided as is without warranty o� guarantce of any kind either expressed or implled Including but not limited to the implied warranties of inerchantability or Titness Tor a paKicular use. All users of Davie County's GIS website shall hold harmless the �ounty of Davie, NoRh Carolina, fts agents, consultants, contractors or employees from any and all claims or causes of action due tc or arising out of the use or Inability to use tho GIS data provided by this website, . . . � .. ` �. . AUTHORI�ATION IVO. . i-"1�� '�M . `� . r - • 1 t� � v��,: , .., . . . ... • . . _ ,.. . . .� _ . � 1-- !'" rJ' . ' s 1 r - , : � �" . � �.. ...'"<. . . . . . ..,. . ♦ , � --• .� ' ; ` � r 1�._ . ic. f �1 � f � `��. ';.c..:� : � �/ ;,� Q�DAVIE CQUNTY HEALTH DEPARTMENT . - . Environmental Health Section • PROPERTY I��ORiVI"A'TTON'----�- --.� F'ermittee's i� �� r . ' P.O. Box 848 � / ��/ li �—� ,�"� Na�e: L-�"� �-�� '"�� (�f `i.=f:' j�� `�j Mocksville, NC 27028 Subdivisi n Name: ' C Phone # 336 751-8760 Directions to property: ��U� '' T�� Section: Lot: ,� , : AUTHORIZATION FOR � ,. , � . WASTEWATER ,� �.,�J<;t'>� >��►j I�,.'�`� L. /'�S."I r•� k-' Tax Office PIN:# - � . SYSTF,M CONSTRUCTION Y'��` I 5�� ' :' i.;i�r,��;,�' �� +��:(:_��,' F1i!-!.. . RoadName: , F �.�1 `- �_"-�Lip:!'_7L�� **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior ro issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie Counry Building Inspections Office when applying for Building Permits. (lq compliance with A�ide 1] � f G.S. Chapter I 30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Sys[ems) '. ; _ !. . ' � . . ***IVOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. IN � ENTAL HEALTF��SPECt ��ST DAT� ISSI�ED � - , p AJ . . _ , � ' _ ' . . 1, . . , . . , - � i` � °'i`F,�� ;� �r �DAVIE��G.O�JNTY �IEALTH DEPARTMENT r F' t'� ( � � 1 �� - 4�� r:- iMPROVEMENT AND OPERATION PERMI,TS �/ PROPERTY INFORMATION � Natrietfee=s . , � `. �,. � $�.. r r ..:`q �� `�� Su� / !�—'�'" � �� ' � �/ - "' . ' , b id visi n Name: ' � �U � DirecGons to property: ��` f'� r' ,�= � Section: Lot: , ' - � � ' IMPROVEMENT ` i 1� ,;-, �.� � PERMIT Tax Office PIN•# - - , , , , . tt, ^ . ; i:`.c?Xt,vCX�OG�� C�-� ., �, � ,. �� s�i 0 � � � � � � Road Name: a. r-�=--t-.Zip: r•,�.. .�i: **NOTE** This Impmvement Permit DOES NOT authorize the construction or installation of a sepdc tank system or any wastewater system. An AiJTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCITON must be obtained from this Department prior to the construcUon/installation of a system or the issuance of a building permit. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ."- "''`�""�< J ***NOTICE*** THLS PERII�IIT LS SUBJECT TO REVOCATION IF SITE w.-- =•'`, � `' �f • : ;l-; i PLANS OR TI-IE IlVTENDED USE CHANGE. YOUR WASTEWATER ? s'-� -, ENVIRONMENTAL HEALTH SPEGIALIST DA'f� ISSUED SYSTEM CONTRACTOR MUST SEE TIQS PERNII'I' BEFORE •• � INSTALLING TI� SYSTEM. - � RESIDENTIAL SPECIFICATION: BUILDING TYPE r�► �-t # BEDROOMS �# BATHS �"? # OCCUPANTS �_ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILTTY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WAS'I'E: Yes or No LOT SIZE � ��-%�- `� .TYPE WATER SUPPLY ..x�� i � DESIGN WASTEWATER FLOW (GPD) �� NEW SITE REPAIR SITE +'' „ 1 SYSTEM SPECIFTCATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �'�', ROCK DEPTH �~ LINEAR FT.?r' � nTUFu � '� � �� J`' ,� X �-S REQUIRED SITE MODIFICATIONS/CONDITIONS: I IMPROVEMENT PERMIT LAYOUT ��c�ST�a� �.'�'�-? .J � U �Q �, u�f t, l- ��.� r�S-t L� ,,�. (JG`r Cl=��S LX l :J7 ! LC �..J C :`�7� 1 �.1 .—� �; � ►� �;:.%.f' { t.�' v ��- � Es�' . �. � ir'EA EFFLU�iVT FIL7ER�- �T2IS�E�tS) IE= 6" £�1.Ot� FIEiI�H�D Gf?A15y�.4 .,.''''�'`� t C uT TN 1� Lt�c c�� F ;� 4- ��. �� . y ..a �. :� � � ��:�2� � **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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 63434 7�Qb� �� {XDix --. I OPERATION PERMIT SYSTEM INSTALLED BY: �F-Lo�3�= ST ��.� � } � � ��T � 4T �— �� AUTHORIZATION NO. �� OPERATION PERMIT BY: DATE: `� �4 d v **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SY EM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OS/96 (Revised) , � � � �� ,.�'i�r° ' F `� . ., , = < 4,�-�-- ,. - ► i„� �- .§ DAVIE'�OI�JNTY HEALTH DEPARTMENT �.-- `•- TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION � Fermittee's � . '�� . .,di... 1 �, �,,. � � _ f~, � �-% ,f✓^ : ,,,.r�. ' .. . ' . 4 f . • ✓'. Name: " � "y � f � �= "' '� Subdivision Name: -. .. -. � , �.,_.,� �,- �__ •. ,. � J� ,�, '�: 1..�'; b Dixecfions to property: � � ' %' ' Sec[ion: `-� - �:d Lot: �� i; t;t i Il�IPROVEMENT PERMIT % Tax Offce PIN:# �'c X� �.st�ts: ,�}.� :_i`.= Road Name: � --� Zip: ; **NOTE** This Improvement Perrnit DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the conshuction/installation of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) " � 1 ***NOTICE*** TI-IIS PERNIIT IS SUBJECT TO REVOCATION IF SITE =�,i ,�' ' PLANS OR TI-� INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DA'I'� ISSUED a SYSTEM CONTRACTOR MUST SEE THI.S PERNIIT BEFORE INSTALLING TI� SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE 1 � # BEDROOMS a�� # BATHS "` # OCCUPANTS �_ GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFTCATION: FACILITY TYPE # PEOPLE # PEOPLElSHIFI' # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE at ��'�: ��, U TYPE WATER SUPPLYj` ,f �'%� DESIGN WASTEWATER FLOW (GPD)'`J �� NEW SITE REPAIR SITE +`" SYSTEM SPECIFICATION�: TANK SIZE ' GAL. PUMP TANK GAL. TRENCH WIDTH .�+'�' ` ROCK DEPTH ��" .` LINEAR FT. ��" �-"� 9 � � �' € Z' ti<... G( l;^ :, ti', �- --' a � ' REQUIRED SITE MODIFICATIONS/CONDITIONS: t � �-�� IMPROVEMENT PERMIT LAYOUT �, , �. �t ti�i'„r�; �.'�`�-� 1 C �� , l:r f f_ i i" �.. �..' w' l;;�"s L' r"'1�=, ��C:> f'�i G'i C: r.-i:.`�` ^, � ;,,.b_�'>"1'. �� f i��r�JVF�D Ei=FLtl��-"tdT �`%LT�R� �F�I:��f:C�) '. `s ' : �' t �, � .�.�. .., j . �' ( �� ;f � F`" p E i � 1 � � Y�l.� � .:: � � .; :• F � w ,, � ^� ',, � F � � 11( ; t ��i , +,.: : + '� ! g{ 6 �� .J y � �r 4dy _ . ..l 4: T";�,rK'.C.4..�1: �� y t..L. �:� �}T -r�ti �� , i._ ►rJt. �.' G �- ;.r i �...� i: `. ��i !`�... ! .._. �, :� C�i:.� - t ;� ;C�� i_.:�1�' . t� � .. �,< TF fs' � L?E�C1?�) �Y{'��.e.�}{:�D �R?�I;`9! r "� + .� � �� .,;' ��. ; �.�,�. ~ �_->> �a.� � ��;:�r_ � **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 930 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634y$�i�pl�?iX)42ttL ��«�. -ra _n-�r I OPERATION PERMIT SYSTEM INSTALLED BY: ►..}h...,,r A �r- �,,_cj�,�.�- �i "C� L� � �� hT � ,.. � I-� l:'r 1_ 13�X tl .----- .__------ AUTHORIZATION NO. _�a�_ OPERATION PERMTI' BY: "—'----- �, `�� J`� '�� DATE: � �a b� ' � ' **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I1 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A'I GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. � DCHD OS/96 (Revised) NAME G�C'i'(// DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) o,jJet' �7 PHONE NUMBER �� y�� % ADDRESS �1�� QUJCC[1Ga�C!`Cc� /�d, SUBDIVISION NAME �%U G �L.S !/< /�G- �G �� LOT # DIRECTIONS TO SITE/��-�r��s: ��,�1-��d�C..�%�u'/�i��. o"n ��'-��, �f'�7`o '�� S� %s CG.��.-�- O��G.��G�� G�. f2� � C�e��Ur�� DATE SYSTEM INSTALLED 0 NAME SYSTEM INSTALLED UNDER �%LG9��'`s�/��/t� � TYPE FACILITY /� �� UMBER BEDROOMS 'y NUMBER PEOPLE SERVED L� TYPE WATER SUPPLY GG"�l� SPECIFY PROBLEM OCCURRING (�t'��f�j ��T�/'�.S (,c� �'� %�`1e� e�� t1 e� Ct � e cr� � DATE REQUESTED /�/��Gd INFORMATION TAKEN BY i�''�� This is to certi}y that the information provided is correct to the best of my knowledge, and tt�at I SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev. 1/93 all charges incurred irom this application. /��/�9Q�o- �'��a��y� ,,�� //y� ��-/-�i�l�" 04/20/2000 • COUNTY OF DAVIE WATER PAGE 1 14:48:59 U/B CONSUMPTION HISTORY REPORT ubcnsinq ACCOUNT # CUSTOMER NAME PARCEL LOCATION STATUS SERVICE MAN METER # READ DATE BILL # CURR READ USAGE REPL USAGE CHARGE AMT ------------------------------------------------------------------------------------------------------------------------------------ 00517280 201897 KOPETZKY THOMAS 386 BOXWOOD CHURCH RD ACTIVE 11 - 1 WR-WATER U 0311R 03/06/2000 26255 40,100 14,600 0 56.19 11 - 1 WR-WATER U 0311R O1/06/2000 18734 25,500 18,600 0 67.27 11 - 1 WR-WATER U 0311R 11/03/1999 15549 6,900 6,800 14,600 75.75 11 - 1 WR-WATER U 0311R 09/20/1999 122765 33,900'�"' 0 .00 11 - 1 WR-WATER U 0311R 07/13/1999 122766 36,600i"' 0 .00 11 - 1 WR-WATER U 0311R O5/13/1999 122767 26,900 0 .00 11 - 1 WR-WATER U 0311R 03/09/1999 122768 26,500 0 .00 11 - 1 WR-WATER U 0311R O1/13/1999 122769 10,000 0 .00 11 - 1 WR-WATER U 0311R 11/12/1998 122770 20,000 0 .00 11 - 1 WR-WATER U 0311R 09/14/1998 122771 6,300 }0 .00 ** END OF REPORT ** , . .. , � .. ; .. . . . - - . �✓.�Co Ai?'�'Hd�I��TI�JN NO: �+� �� DAVIE COUNTY HEALTH DEPARTMENT • ��,, � Environmental Health Section PROPERTY INFORMATION Permittee's r�`/'� � �r ,�,� ,,�.�.�'' P.O. Box 848 Name: � --�)a�'�f � t��,�.^�, a��e'/��,:'?� ,�r� �.� t s� k �W ,�'�, Mocksville, NC 27028 Subdivision Name: � . Phone #: 704-634-8760 Directions to property: r� .�g �`% i:- '.� i � Section: Lot: AUTHORIZATION FOR WASTEWATER �•:-�-�s-+! r'' /fw .f SYSTEM CONSTRUCT'ION Tax Office PIN:# E'� �; •��,"'M' -�, ;�r�;s4 ,,Q . � �C ' i�:D�� q'Road Nam�';c?l'��"r ��i�'��' **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLTED by the Davie County Environmental Health Section prior to issuance of any Building Pemuts. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.3. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) �,��',%�� %�^/� ,i' `�,7 ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ,/.�� !:� Gl--'�r� ./` ;,�,r :�� '��i� IS VALm FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED _ , „ , „�,. „ , : - . `'0 _ , . _ ,. . _ . ..,,.�l. -�,, 6' ' � " . . .. . � . . ' {n ' ' . .. . . ,� ,�•° \ p� �,� dk„ �� DAVIE COUNTY HEALTH DEPARTMENT � p �= A, ;^;,, �, TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permitt�e s'"'� `;�.� � ..s --- , �,� � . Name: � �.�; �' �� R , y� � �,,, � f' �, ?%"'. } � ,� �, tri �� r �� Subdivision Name: � "� .� � � . Directions to property: '�:� ,�' r': .� 'J Section: Lot: ' r� IlNPROVEMENT PERNIIT Tax Office PIN:#.�'"�� ' r_ s_�� k•1 ` ! �'_ �� ' ` � ' 1 , � . j �_ a r - L C � ��-=�-�'�--�U;�.��+ ��Road Name � : e i i �t ��:� ��^' ��Zip: �. r ��' %i' **NOTE** This Improvement Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUTHORIZATTON FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained frc�m this Department prior to the construction/'mstallation of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) -',! : � _.. ***NOTICE**'� THIS PERNIIT IS SUBJECT TO REVOCATION IF SITE ' �`� :`r-- ',,• .�,'` � r, ;-% 1 j' * j,d`,�''' �. �-''� :' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING TI� SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE �1 �# BEDROOMS �r # BATHS -� # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLF✓SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE ✓� C' TYPE WATER SUPPLY `" DESIGN WASTEWATER FLOW (GPD) �l� NEW SITE � REPAIR SITE � �' �� SYSTEM SPECIFICATIONS: TANK SIZE +/��P� - GAL. PUMP TANK GAL. TRENCH WIDTH `� � ROCK DEPTH .�� LINEAR FT. .Sf �'' -``, OTHER . ' REQUIRED SITE MODIFICATIONS/CONDI'I'IQNS: ^y r IMPROVEMENT PERMIT LAYOUT \ � �� ' t� � ,-''r"` � � - 1�, � �Ga .� .�i�? -71� ��t✓ **CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPF,(i'i'I Q�' TI/IIS SYSTEM BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:�0 P.M. ON THE DAY OF INSTALLATION. TELEPH�� E#�j (�� 3 �760. � OPERATION PERMIT �---��-------� �" ° . " ?D BY: C��'�� :q �= � /D� 1i1 c� � AUTHORIZATION N(�_� OPERATION PERMIT BY: DATE: � �� **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OS/96 (Revised) .� �� APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC � ' � � � • Davie County Health Department ' � �� , Environmental Health Section D � P.O. Box 848 Mocksville, NC 27028 �� — 2 �"'� (704) 634-8760 � _ '�'�*'�IMPORTANT**** THI5 APPLICATION CANNOT BE PROCESSEI}�1 THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed ��'`�*�i �� Mailing Address �� C. � � City/State/Zip � �`�"ern'L�� nC o2�� 2. Name on PermidATC if Different than Above Contact Person 0 Q� Home Phone �� `t''" �-� �� Business Phone ��' a�� J Mailing Address City/State/Zip 3. Application For: [] Site Evaluation [] Improvement Permit & ATC fvj�Both 4. System to Serve: [] House [�Mobile Home [] Business [] Industry [] Other 5. If Residence: # People # Bedrooms � # Bathrooms [ �}'Dishwasher [] Gazbage Disposal [ �Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify type # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Esdmated Water Usage (gallons per day) 7. Type of water supply: [�] County/City [] Well [] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [] Yes [� If yes, what type? Ciirirc: f� YLftL u« �1 PROPERTY INFORMATION REQUIRED: *** IMPORTANT **''XL�,� OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: �-�--C�TI 0.�'—� �'Y�� WRITE DIRECTIONS (from Mocksville) TO PROPERTY: Tax Office PIN: # ��,3�f' _ � S _ `t'"3 � � (Q � �- � � IVO1�W D 0 �(, PropertyAddress: Road�ame CH�rw� 4�1 �� {GL � v�"Iw�� L�' � a�- City/Zip �� pSU 1 � �G a%0.�,� � V{'l.Q�{� (J�" D b�, If in Subdivision provide information, as follows: � Vy<<'t-Y� � � � Y�% '�?�� ! � Name: � � � Section: Lot #: ; This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter aze subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above d ribed property located in Davie County and owned by /�,W/�v p• ��` l�.Q�fL to duct all testin oce s as ne to determine the site suitability. DATE z' a �' �� ' SIGNATURE Revised DCHD (06-96) THIS ttREA �IAJ 23E USEb �OR �RAWZNG JOUn SZTE YLAN: .. \ � . _: i . . . . �.>. �\ \�� . . .. ' ' i \ � � � � � ��1 � � • � ` /�lr�� l l ��1�, �! � / � / `I �/% �/;,`�/��. �� .. 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' � '• : • DAVIE COUNTY HEALTH DEPARTMENT . � Environmental Health Section � Soil/Site Evaluation NAME .'/� DATE EVALUATED �/ /�� /�� ADDRESS PROPERTY SIZE / %�� PROPOSED FACIILTY ��%� �`' LOCATION OF SITE G J i't/� ��ZJ� Water Supply: On-Site Well Community Public 1� Evaluation By: AugerBoring Pit Cut FACTORS 1 2 3 4 Landsca e osition Slo e 7. HORIZON I DEPTH Texture rou Consistence Structure Mineralo HORIZON II DEPTH " f` �6 �`' Texture rou ' Consis tence .i� Structure S'�,� Mineralo ,-i HORIZON III DEPTH Texture rou Consistence Structure MineraloRY 'rexture group Consistence Structure Mineralo�y SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLaSSIFICATION LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: EVALUATED BY: LANG-TERM ACCEPTANCE RATE• 1 OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge 5-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 SI�L-Silty �:lay loam� SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR- Vcry friable FR-Friable FI-Firm VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structurc ,iC-SYngle grain M-Massive CR-Crumb GR-Granular ABK-AnBular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Minerel�gy 1:1, 2:1, Mixed Notes Hori2on depth - In inches Depth of fill - In inches Restrictive horizon - Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil w etness - Inches from land surface to free watec' or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 ■��■■��■■��■■��■��■�� ■��■ e ■� ■�� ■��■ ■��■��■��■■��■ ��o��■ ■��■��■■�■��■��■��■■■��■■■ ■�■��■��■��■��■��■■��■��■��■��■��■��■ ■��■��■��■ ■��■��■■��■��■��■�■ ■��■��■��■��■��■��■��■■■��■ ■��t��s��■��■ ■��■■��■��■��■��■��■��■��■��■ ■�■��■�■��■��■��■��■ ■��■��■�■��■��■ ■��■�■■■�■��■ ■��■��■■��■��■��■■■ ■�■�� ■��■�■��■■■�� ...........................C...................�.................. .............................................. ........ .......... ......................................... ....�. ......�...... .. .....■...................................�..■..■�...■..■.....■:�■. .................................................................. ................................ ................................ ■��/��/��■��■��■��■��■■i��■ ■■■��■■�■��■��■��■ ■��■\\��■��■�■��e��■��■ ��■�■�■�� ■��■�� ■■��■�■�■��■■■■ �/��■■�� ■■��■��■■��s��_��■■��C��■■��_■ ■��■��■��■�� iiii�iii�iiiiiiiiiiiiiiiii�iiiiii�iii■i�iii�iiiiiiiiiiiiiiii�=iii ■��■��■��N��■��N�\��■��n\��■�� ■��■��■��\ �� ■■��■��N��■��\��■■��■■��■��■■ ��■■��■ ■ .....■............................................0 .............. .......................................................■.......... .................................................................. 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Box 84�8 � Hospit�il Street Courier # : 09-4,0-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection I'�.x: (336) - 753-1680 Name: � �/ Phone Number I��`�� - �� (Home) � � Mailing Address: � ;�y U � �C S I_ 7l>`'�� ,�3 � ^ /S�� % (Work) ,.S�a �s ar, A/G- �'y� . DetailedDirectionsToSite: /�'ti� �l�� .Sv � G/ily'✓' /��//S��r ,v � '''z��' `�T� 3 �3 � �� wc��r - ' � Property Address: (�!I b�Lr✓Y. h. ' Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: ��5"� ��l�G� Date System Installed (Month/Date/Year): �� ' Number Of Bedrooms:�Number Of People:_� Is The Facility Currently Vacant? Yes � If Yes, For How Long? Any Known Problems? Yes No If Yes, Explain: Please Fill In The Following Information About The NEW Facility: S-;.� Type Of Facility: Requested By:_ Approved � Comments: Disapproved Environmental Health Specialist " ' Z�Ik3�� . - s: Num er of People Date Requested: r� CC� �a For Environmental Health Office Use Only Date: *The signing of this form by the Envirorunental Health S`taff 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 # /`�(.J`� Amount:$ (,j ►� ffJ Date: �"/.,�//U Paid By: � (�� Received By: � (�� Account #: � �� Invoice #: ��1 _