4177 Hwy 158 . D AVIE CO • _ , HEALTH DEPARTMENT
i
Name:' -- i �••-- �� - �'+ 1�1V�.h7 ( nental Health Section PROPERTY INFORMATION
* •Ai► ��)'t t�T' P.O.Box 848,
bisections to property: E- Mocksville,NC 27028 Subdivision Name:
ai 40 1 ' , • � � ( Phone#:336-751-8760 Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
j SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: Y A Road Name: rl�� `1 Zi c
P-
**NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits.This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with icle.;1.1of G.S.Chapter 130A,,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
T;'� IS VALID FOR A PERIOD OF FIVE YEARS.
ENV,IRON09NTi4L,}IE t TH SPE IA(157/ DATE SSU D
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
Ct:I�Ce✓�Slo+�S�oaD
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
L� J���� NEW SITE REPAIR SITE
LOT SIZE ' I�'�"TYI�WATER SUPPLY DESIGN WASTEWATER FLOW(GPD) Y
SYSTEM SPECIFICATIONS: TANK SILGA GAL. PUMP TANK GAL. TRENCH WIDTH - ,ROCK DEPTH r 2 LINEAR FT.
OTHER v 1 tLtd�T l iob T 2 AO F"tzt:rA
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT—
crz
s-ra Ac%a �.---�e Ll N)i 1 Gt _It��J
1evil) 5I ,
Al t.Qter-
I� •
**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 (336)751-8760.
OPERATION PERMIT
- SYSTEM INSTALLED BY: —A
SYSTEM
/Or
N \� •
k ' •
3-
AUTHORIZATION No.:X7 OPERATION PERMIT BY: �' DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S M DESCRIBED A OV S BEEN INSTALLED IN
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 02102(Revised)
*::V.
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PER& IT R. ATV
Davie County Health Department D (,
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 AUG 2 2�:_
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLES ALL THI6AAE ZI�,ftD
'INFORMATION IS PROVIDED. Refer to the
INFORMATION BULLETIN for instructions.
1. Name to be Billed �iJ7t�/� /Vj`eti / O�M� y Contact Person •
Mailing Address
���(; �S� Home Phone
City/State/ZIP �G�,(!1'y,�//P Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application ForSite Evaluation Improvement Permit/ATC ❑ Both
4. System to Service: /❑ House ❑ Mobile Home ❑ Business ❑ Industry 13eOther
5. If Residence: # People # Bedrooms # Bathrooms
1.1 Dishwasher CI Garbage Disposal EI Washing Machine El Basement/Plumbing EI Basement/No Plumbing
6. If Business/Industry/Other: Specify type a4"�r/,'� # 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? ('Oc)/v. S / C� �f-r S+ r �: 5 /�_.
'IMPORTANT'CLIENTS MUSTCOMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
t
Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN:• # ��lnl/�f 30 a �L�, X17 64X r A"�,.�,�-�
Property Address: Road Name y zd �,.,•Z! /��e�� �',PL ,G/off
City/Zip
If in a Subdivision provide information,as follows:
Name: '
�h
Section: Block: Lot: Date Property Flagged: S -1 "? --�
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 front
this application. 1,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
to conduct all(testing procedures as necessary to determine the site suitability.
DATE e /3 0 SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No. t .
Revised DCHD(07/99) Invoice No. ( 3
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT&AN FEB — 6 2001
Davie County Health Department �J
EnV/ronmenl'd/Hes/bfSerC6'onENVfRONtOENTAI HEALTH
P.O. Box 848/210 Hospital Street D1 COUNTY
Mocksville, NC 27028
(336)751-8760
***n2P0RTAN7`*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDEjjD.n Refer /to the INFORMATION BULLETIN for instructions.
Name to be Billed �i✓I;T/I !!'/d i/P /O �• i, fiep7e4contact Person '
Mailing Address A&I, Alf Home Phone 53& 9ya ^ u, J�(S 7
City/State/ZIP L1•Yj'�. Ile a �70Ze Business Phone 3& 5®1' -�-y
v` "D
2. Name on Permit/ATC If
Different than Above
Mailing Address (/f�� /�/Olin�f City/State/Zip �/��rii.'�/G /II•C �7D��'
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4, system to Service: O House O Mobile Home O Business O Industry O Other
5. If Residence: # People # Bedrooms # Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
If Business/Industry/Other: Specify type # People # Sinks
✓✓ # Commodes # Showers # Urinals # Water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: W County/City O Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑Yes O No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: WRITE DIRECTIONS(from Mocksville)to PROPERTY:
Tax Office PIN: #
Property Address: Road Name
City/Zip
If in a Subdivision provide information,as follows:
Name:
Section: Block: Lot: Date Property Flagged:
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
to conduct all testing procedures as necessary to determine the site suitability. �J
DATE SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS•
Account No.
Revised DCHD(07/99) Invoice No.
1
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478.772 74.146 6 9 '
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E600000091
SMITH GROVE'COMMUNITY CENTER
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Parcel#: E600000091 A Page 1 of 1
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Davie County, NC - Basic Estate Search n M%
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Parcel#:E600000091 A Account*:67271500
Owner Information Tax Codes
MITH GROVE COMMUNITY CENTER ADVLTAX-COUNTY T
O CHARLES ALEXANDER READVLTAX-FIRE TAX
EDVANCE NC 27006
Property Information Township
nd(Units/Type): 11.440 AC FARMINGTON
Edress:4177 US HWY 158
Deed Information Local tonin
Pate: 12/1990 Book: 00157 Page: 0345
Plat Book: Page:
Le al Description PIN
12.21 AC HWY 158 5861173008
Pro a Values
uildin 303,17
BXF: 82
nd: 138,58
arket: 442,57
ssessed: 442,57(
eferred:
Sales Information
No. Book Pape Month Year Instrument Qual/UnQual Improved Price
00157 0345 12 1990 WD Unqualified improved 0
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
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All information on this site is prepared for the inventory of real property found within Davie County. All data is compiled from recorded deeds,
plats, and other public records and data. Users of this data are hereby notified that the aforementioned public information sources should be
consulted for verification of the information.All information contained herein was created for the Davie County's internal use. Davie County,
Its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or
Implied, In fact or in law, Including without limitation the Implied warranties of merchantability and fitness for a particular use.
If you have any questions about the data displayed on this website please contact the Davie County Tax Office at(336) 753-6120.
1.5.9
http://maps.daviecountync.gov/itsnet/View.aspx?prid=1475401 6/16/2016