695 Burton Rd (2)Davie County, NC � Tax Parcel Report Tuesday, October 11, 2016
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage:
Deed Date:
Deed Book I Page:
Plat Book:
Plat Page:
Building Value:
WARNING: TIIIS IS NOT A SURVEY
Parcel Information
1900000019 Township:
5798147874 Municipality:
51654500 Census Tract:
MOONEY PETER JOSEPH JR Voting Precinct:
695 BURTON ROAD Planning Jurisdiction:
ADVANCE Zoning Class:
NC Zoning Overlay:
Land Value:
Total Assessed Value:
27006-0000 Voluntary Ag. District:
5.52 AC BURTON RD Fire Response District:
5.31 Elementary School Zone
5/1996 Middle School Zone:
001870600 Soil Types:
Flood Zone:
Watershed Overlay:
94560.00 Outbuilding & Extra
Freatures Value:
77560.00 Total Market Value:
9 � �+�F
D�vie County,
noop�C� i�C
Fulton
37059-804
FULTON
Davie County
DAVIE COUNTY R-A
f�[.7
ADVANCE
SHADY GROVE
WILLIAM ELLIS
PcB2,PcC2
DAVIE COUNTY
14230.00
186350.00
All tlata Is provlded as is without warranty or guarantee of any klnd elther expressed or Implied Including but not limited to the
Implied warranties of morchantability or fitness for a particular use. All users of Davte County's GIS webslte shall hold harmless the
County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all clalms or causes of action due to
or arising out of tho use ar inability to use the GIS data provided by thls website,.
.
...:�.. �.ta�� � . . . , � �_ _ �1� ' � ' � ' .��'%3���'::a�. a��•,� " � �d' � � ., �'Ca'-.
' AUTxo�izaTloN No: O 8 O 5 DAVIE COUNTY HEALTH DEPARTMEN �3c�" ��' �
' ' Environmental Health Section RO RTY INFORMATION
Permittee's . P.O. Box 848
Name: ��-��'�`���i Mocksville, NC 27028 Subdivision Name: �'�"'"'"
Phone #: 704-634-8760 .- --..�
Directions to property: ��'� �. � �-���b � ��
(�`_ AUTHORIZATION FOR
��\ C`�L�.�. ,sK..�,�,t�,at� ��`�.��.. '" �� WASTEWATER
SYSTEM CONSTRUCTION
�.-...- �-+ `
��'c���_`J �:� ��..`�.x�c� \`,�c , ' "��`'!, ..?�st
Section: �- " ' Lot:
Tax Office PIN:## +��� - i y. - t� r��"
Road Name: rP- Zip: b�1A
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Pernuts. "
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
� � � �� ` ,� ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
��1'`�`?`�-=y`�`� R+J-��' '�-�,� -"�i � IS VALID FOR A PERIOD OF FIVE YEARS. „
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
� . - . � .. . . w. . � ' . . . . . . . . � � . .. � � � .
. ...� ...�.. ..
. . . . ' .. . . .. . ,. . . . � . .
.. : .. . . .... .. � . � .. ;.. . .. . . � . .. �..
� E :�w _ - .-_ . , . , , _ � . . � , ,..» ) -- .� � - . _ A �.�a
...- . , . _ . . . , ,
A .., �Z, .,r . � 7 ,,,,�+ l "� % � � t`� I � �.+ ' } : ��, �.�
— �,Y d . `.� --- . DAVIE COUNTY HEALTH DEPARTME � �;�r��'�_ � r "�'1' �
. .�<..."^,..'T.,...,..f�S . � 'Y
�-:. ... IMPROVEMENT AND OPERATION PERMITS PROP�RTY INFORMATION
• Permittee's �T .
_ , Name:' - �' �_�_R.. �..t��''�,�.4�
� � �i �
`� Directions to property: �: ` ,� ; _` � v ` � �
--- �
, � s i..
; � . c.-. �» .�k _ ~ 'i �'�
� C � � V � `s ., r �"�� � t`'`�� t. c -
IlVIPROVEMENT
PERMIT
Subdivision Name: ""' '
Section: � � ' �? Lot•
Tax Office PIN:#` � f _ ; °:�_ ,..! ^; , "'t t'
�
Road Name: 4 � � * '+ - � r� • Zip: �1C �j � j,�
**NOTE** This Impmvement Pernut DOFS NOT authorize the construction�or installarion of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/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)
'� ', ` �-�. . ***NOTICE*** THIS PERMIT LS SUBJECT TO REVOCATION IF S1TE
_. .. ;'' ;-�.:'� .'' k... �:�,r,,i - 6- t PLANS OR Tf� INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
' �,` � INSTALLING Ti� SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE �,��,# BEDROOMS �� # BATHS �_ # OCCUPANTS "' GARBAGE DISPOSAL: Yes ��
COMMERCIAL SPECIFICATION: FACILITY TI'PE # PEOPLE # PEOPLFISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE �.5 c+.�r'� TYPE WATER SUPPLY �aJ n�i�- DESIGN WASTEWATER FLOW (GPD) �L�r� NEW SITE � REPAIR SITE '�
�, � u �U,
SYSTEM SPECIFICATIONS: TANK SIZE l � p� GAL. PUMP TANK GAL. TRENCH WIDTH J ROCK DEPTH � g LINEAR FT. �-�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
',,
��� ��'
-� ...___,,._
�.�`'�� � �� �
-���-�-----1�
t� �
�
m
�
**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. T'ELEPHONE # IS (704) 634-8760.
I OPERATION PERMIT
� ��
SYSTEM INSTALLED BY: '��"" � �u ��'4��
lbr�K�jd,Tc �/Z9�j7
�"7 S �X 3b"� � g „
� 75�
�� ,
�•l��C w� i..l �G i'J O 1 LQK.i� G�1c�7�
0.T t A�E�,TI �
N' I
AUTHORIZATION NO. 'V �� OPERATION PERMIT BY: ����� ~�"�' "- DpTE: � 9 l
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAP'TER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
\
f
�:
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
� Davie County Health Department
• Environmental Health Section
P.O. Box 848
Mocksville, NC 27028
r�na���a_R��n
*'��*IMPORTANT****
- - �I
THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed � �\\\ Contact Person `� s��S� �\�'���
Mailing Address � � Home Phone ��c� � � �b
City/State/Zip �,� �`ta'�C� `��i C a�.� � �7 Business Phone l� � � 00�
2. Name on PermidATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [�Site Evaluation [y]�mprovement Permit & ATC [�th
4. System to Serve: [✓f House [] Mobile Home [] Business [] Industry [] Other
5. If Residence: # People —" # Bedrooms�_ # Bathrooms � [] Dishwasher [] Gatbage Disposal
[] Washing Machine [] Basement/Plumbing [] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated 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 [] No
If yes, what type?
EZTHER A PLttT OR SZTE �'LttN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A=�'4�OF THE PROPERTY MUST BE
y SUBMITTED WITH T�-II� APPLICATION.
Property Dimensions: � �'� ��4'O � WRITE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: # � � �� - , � -��� ; 6� � '
Property Address: Road Name `C�.aa� � � �� I� ' 1�� 6�(\
City/Zip ��e.sL��N .0 �,1ovl� � ��'P�R.� s �� ` '�� o�r�
If in Subdivision provide information, as follows: � ,JJ�� ti—�'`�.. ��`�r.
� �Q��
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 are
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 described property located in Davie County and owned
by �'� �__a, \� � �
DATE ^ti ��' �1 SIG
Revised DCHD (06-96)
all testing procedures as necessary to determine the site suitability.
THIS ,0.IZEft MftJ 23E USEb �OIZ bl�tIVING fOUlt SITE PL.tIN:
' � r� ♦:'�� M ! .Sa�',� � •_ Y� . _..
� 1 I.. � S ...
' 1 I : �,� 1'.� � . � � .
1 �
'a ,� i �f„I �, I . . n -
`t' ' = '�' � DAVIE COUNTY HEALTH DEPARTMENT
4 , t ' ` .
'° ` � � Environmental Health �ection �
t .•� C k _ / ,. . � . . . . � .
' � Soil/Site Evaluation
t; ; , y � � �,
�x=�� �j,
P 1 ! . .. �. . �
i ' ? °`" ,f � �,�er� � • � � ° � "'y DATE EVALUATED " l V � � ~ �
' `"� �' j,• - _ .
� : I
t ��
;ESS S A �a PROPERTY SIZE �• � ��D
�.�; ; Q
� ,OPOSED FACIILTY ���='�' LOCATION OF SITE �J ��d � � '�°'�� ;
�.... . _
t. ,
�' Water Supply: On-Site Well _ Community ' Public �" � `�
�;, ,. .:. .. '
/` Evaluation By:C��—AugerBoring Pit Cut 4 ' '. �
_ . ,.
�' .,
� FACTORS a• 2 3 4 ,.
,'�Landsca e � osition S ��.
� iSlo e R �'� _
� , `HORIZON I DEPTH " �o� ' ` ' '
,� ' . -Texture rou '' �-- � _ '
��;:ConsYstence �- ' _
� 'Structure C'
. � _.., . ;,. �. .._. ..
Y; _ Mineralo � , ...,.... .. , ,. . . ,
�" ;HORIZON II DEPTH �� .1.` , , l . `- ,
�Texture rou C. �
( !� _ ConsistGnce _-�=� _, �_.. . ; < , .�. .;. . �
' Structure F�$�. �
� MineraL� 1'.1 � _. _:. ._ ... _. , �...; .:;
�; : HORIZON III DEPTH . .. _ . _. , .. . :
j � Texture rou ..
1 Consistance
-Structure
� �Mineralo
. :�;HORIZON IV DEPTH ., . . . ,
., ; ; Texture rou _. _ , _ :
'.. Consistence " ; , '
� � �,
:, `. Structure _.,, : . .._ .;._:_.. � ,�... . , . . ,
� �Mineralo �
' SOIL WEfiNESS .�' SS , , .., : -,: '''
RESTRICTIVE HORIZON -- -� , , _.. .,...
SAPROLITE .r —
�
CLASS.LFICATION . S _ .S '
LONG-TERM ACCEPTANCE RATE '"
SITE CLASSIFICATION: �� �-• EVALUATED BY: ���� �?�'���•' y�
LDNG-TERM�ACCEPTANCE RATE: y� _.�_ OTHER(S) P ESENT: ����a�'�
; . , REMARKS: � ' - �, ,; .. i s�,1' ......`
.� _ �-er-?�.� a�� � EGEND _ . . . .
. c�� . . .
,, , ,
• Landscape Position - - •-•
---� 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 _ ,
8; �- 5-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt •, ; �
_ - SICL-Silty -;lay loam• SIL-Silty loam CL-Clay loam SCL-Sandy clay loam '
�__.- SC-Sandy clay SIC-Silty clay C-Clay
PE� , ' , CONSISTENCE ..
i ' . . �at .
� ; VFR-�Va.ry 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 � '... ...- - " " '
� -.. � . , .
� . . . .,
� Structure
' ,iC-Sinfile grain M-Massive CR-Crumb GR-Granular ABK-AnQular bloeky_
� SBK-Subangular blocky PL-Platy PR-Prismatic -
"� � ,
Mirieralo¢y '
1:1, 2:1. Mixed �• '�
No#es
Horizon depth - In inches --
Depth of fill - ln inches
Restrictive horizon - Thickness and inches� from land surface '
Saprolite - S(suitable), U(unsuitable) � ,
Soil wetness - Inches from land surface to free wate�' 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 - gal7day/ft2 ,
r
; ,: _ : _ , �=:: -. .: �
,_ ,. . ,.,,, . ;- , ;_, . .'. . :.; ; �
� ��—.S ' � �1.., �. �.aa.s� t Q � Q
" AUTHORIZATION NO: O 5�I 5 DAVIE COUNTY HEALTH DEPARTMENT ��
:, _ Environmental Health Section PR RMATION
Perinittee's • ,___ P.O. Box 848
Name: �'� -���'.�.. �•�t��Q ��y�`� Mocksville, NC 27028 Subdivision Name:
� Phone #: 704-634-8760
Directions to property: �% �� C`��`��Q � t� Section: Lot:
AUTHORIZATION FOR ,
•,.;, �...�� t�t . c;c'�. WASTEWATER 7 t� t.� 1
,�.y >..r�.�r��. ��.�.w:�'�.. ` �� Tax Office PIN:#_,�--r�- - �_ �
' SYSTEM CONSTRUCTION
�ti � °���,��.��� ` � �a er`.'� �� `y�,�.��y Road Name: �?�i�� a �� ��'�. Zip:�' (� a �
**NOTE** This Authonzation for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for �uilding Pemuts.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
C�. �, ***NOTICE*** TffiS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
.��:. ��r� �-:-�� -�� 4� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST ". DATE 1SSUED
:. , . : . _
. � . , •� . _., , ._ . ,: ,. : ,
��, �, �� �`' ' � :; �� , , , .. . � �� : .� � � �l�%�.�' ' �'-. ..�> �� ,�� �; � � �3 ,.� � � ✓ X �
-- � _ DAVIE COUNTY HEALTH DEPARTMENT , -°
Y�� p�"'''�"'`���� - - IMPROVEMENT AND OPERATION PERMITS PR E��RMATION
o.
Pernuttee'�s »
I�ame:.
r .;:y , �' i C`.,..3 t..y r. .
.�.: ��
.: .. ,," -` #y �.: ;_ - � ; t'i
� • Directions to property: " '�,� _' ' `' °
`4t,'.�a4,' .. .. . .. . ... ' ��.r.� .� .
� _
; �. _ �, ,
..r �: � ' : `�• ":.t .: �.. ._t , •.•
.`
IMPROVEMENT
PERNIIT
Subdivision Name:
Section: Lot: .
Tax Office PIN:#�=�---';'- - `�i - � r`=^�^�-,
, �
} ' ^� � �
Road Name: t t•t`''; � • , '�'`, �, Zip; c + � �,
**NOT'E** This Improvement Pernut DOES NOT authorize the construction or installation of a septic tanlc system or any wastewater system. An
AUTHORI7.ATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
,,conshuction/installation of a system or the issuance of a building pemut.
(In compliance w,ith,Article,l l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
,
. f �` / / - �-7 / .2�! ; i./ , .
1�,, �x'-�,"x-i�._l-�.I> � i� °l.S:�>:� �' _ .`.�. "� � �
ENVIRONME AL ii$ALTH SPECIALIST ., DATE ISSUED '%
�; � ..
� � �,_ . _ .
RESIDENTIAL SPECIFICATION: BUILDING TYPE u� u-sa # BEDROOMS
.� � n. S . ' . .
COMMERCIAL SPECIFICATION: FACILITY TYPE� # PEOPLE
'���`iVVtll;i';�'�" 1tLJ Y�1(Mll' 1J,UlfJt'.�-1' "1'U Kr:VVI:A'1'lU1V lr'Jl'1'1:
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE
INSTALLING THE SYSTEM.
� # BATHS � # OCCUPANTS � GARBAGE DISPOSAL: Yes or No
# PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE S�S v�TYPE WATER SUPPLY`� °�`�- DESIGN�WASTEWATER FLOW (GPD) � a NEW SITE REPAIR SITE �r
��
SYSTEM SPECIFICATIONS: TANK SIZE � p�`� GAL. PUMP TANK GAL. TRENCH WIDTH 3 ROCK DEPTH r Lf LINEAR FT. �
' � OTHER ' � 1 \ 1 � r��^ Q\ C�'� � r3> `c� ��, � \ ��'C '' U � F .,..t 1 t�, 9
. -,
REQUIRED SITE MODIFIC�ATIONS/CONDITIONS:
� i. '
I IMPROVEMENT PERMIT LAYOUT
�
I-�dV�� �
m
. . y
� � '
/� n ' .. ;^ . ' . ,.- ..
"l J
� + •
**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) 634-8760.
I OPERATION PERMIT
�.�
� ��..,�w � �,�, .
_...._._�... �,��;;;
YSTEM IN ALLED
r .. _ A ��r ���
. `��-� �
r
� �/D /
AUTHORIZATION NO. �� OPERATION PERMIT BY: , �Lfi� DATE: ,� ��lo
**Tf� 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)
- .. . ,
: �- � ...; .
; - .� 9'l�;T�. `� ��"�- .. ,✓`k"c
�* _ .
' �` ' - g : DAVIE COUNTY HEALTH DEPARTMENT ='� '. , :' ��
�' d-�-�:,--�,�� '�
� ;.'�. "'�' "'�� h- - IMPROVEMENT AND OPERATION PERMITS PR PER�Y-iiV RMATION
Perniittee's' ;� . '
I�fiame:. " . > � . .
. .-.-
, • Directions to property: � �
�, , '•� �;�•, ,,. �
.�::., ,:.
� , `. .
Subdivision Name:
,
Section: Lot:
IlVIPROVEMENT
PERMIT Ta�c Of�ce PIN:# w.-, '- .,
�. ..=�-��.
` t.
Road Name:�+ � ' ' Zip•' �i _�
**NOTE** This Improdement Pernut DOES NOT authorize the construction or installation of a septic tanlc system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/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)
� , . � ,i r
'` � �• ' ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF STI'E
`''�. �. :::� �,, �, '. `` � �-s_°� �'� . �. � '�� PLANS OR Tf� INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
• , INSTALLING TI� SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE U� �S� # BEDROOMS � # BATHS � # OCCUPANTS �r GARBAGE DISPOSAL: Yes or No
. . . � r. . �,,., ,
�:. � . �� i . .r � , t.--
COMMERCIAL:SPECIFICATIOI�T: FrACILTTY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WAS1'E: Yes or No
LOT SIZE J��`�' TYPE WATER SUPPLY��� �'�'f• ' DESIGN WASTEWATER FLOW (GPD) �� J NEW SITE REPAIR SITE ��
1 �'� �, ,� / ` ! "'� �i
SYSTEM SPECIFICA°CIONS: TAN$-SIZE � U� GAL. ,�'iJMP,TANK�GAL. TRENCH WIDTH % ROCK DEPTH �� LINEAR FT. ���
C, ' " ' �
` (a '`�, �
i
OTHER �\ 1, ''�' Y �'";��Q���. � £` `c''� � \`�� ' <J �'�, • �< <V �
� E
i - � f �
REQUIRED STI'E MODIFI�ATIONS/CONDITIONS:
IMPROVEMENT PERMTT LAYOUT
r
...---.'r
i-�dvs�4
u
�
�
7 �
/�� � ,
ti �
� ---.� ` ,
--'�j �
**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) 634-8760.
I OPERATION PERMIT
��
,� � �r.
n.. ,y y ,
� 4 r..a...w..«., r���
YSTEM IN TALLED
!d � {
.. . . � • � � .1 � %` � r-,
/7
r
AUTHORIZATION NO. �� OPERATION PERMIT BY: ���� DATE: , %!� ' �i1 ' �'/`�f-"
**TF� ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAP'TER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A
GUARANTEE THAT THE SYSTEM WII,L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD OS/96 (Revised)
, i�
,n
3 : � �u.�
R�� DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
' APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME Q�� J� � o d�J ��l PHONE NUMBER ��g � l'2.�1 v
ADDRESS C� �� �v �� �� � a SUBDIVISION NAME
��+v��a�ca `'�i.C. �,1OB� LOT#,
DATE SYSTEM INSTALLED � NAME SYSTEM INSTALLED UNDER �
TYPE FACILITY ��sq NUMBER BEDROOMS �' � NUMBER PEOPLE SERVED �
TYPE WATER SUPPLY �.1 •�T�• SPECIFY PROBLEM OCCURRING ��s.�� ��
� .�.� ������ •l>��
DATE REQUESTED �"�-y �� INFORMATION TAKEN BY \�����
This is to certify that the information provided is correct to the best of my knowledge, and that 1 under nd I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT ��"� �
Rev. 1/93
� �ie j�'
�
Davie County Health Department
Environmental Health Section
P.O. Box 848
�,�,, 210 Hospital Street
'� Courier # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: _ P�/'�-- � YG�oOlV 2t� Phone Number �� �'� �%Z�� (Home)
Mailing Address: � �'! � �%�.��i� � ��C �g�% — �'on y (Work)
���"��. NC'_ 2'70 0(r� Email Address: _,p1�.S' �'�eS�� /�-UL� � Co rz'I
DetailedDirectionsToSite:FYZt�v�'L ��i S��-� �-L�y✓ %GY� ��L� �2(�p��S' C,..rcxs�K� /'��4��
� O Y�� � �2.� r�e./-� Q-�i"-� .,��.c2�-u�.;� �� � �� / •� N�. �
.��-ki �4-� . j u.u�.�-r`o.v ci F �'vrwr�.ee._�-r,a.v /G� �-� � L2
Address: 6� � _��t2-�� /c�,��-�(
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility:
Date System Installed (Month/Date/Year)�G�a ��� j°�}(o Number Of Bedrooms: � Number Of People: �
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type OfFacility: P�AN� t,vL4�Ny �oN'1 Number OfBedrooms: Number ofPeople
i /
Pool Size: Garage Size: Other: ZG x! o
Date Requested:_ � i � �r1 Z.o %�
For Environmental Health Office Use Only
Approved isapproved
,�A _ ,/ �- / �( �/
Comments: .�v (�3 i�.�G J�/liJ S � s/ J �� 'r% �.� .. �� �� o ti ��
�A
Environmental Health Specialist.
Date: �/ — �'— /� �
*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:$
Paid By: Received By:_
Account #: Invoice #:
�