5073 Hwy 158 (2) t'Pt!r`�ruttec '�' DAVIE COUNTY HEALTH DEPARTMENT
Name:_f1�. !�/,< 'rte'=' < tr/'j Environmental Health Section PROPERTY INFORMATION
P.O.Box 848
Directions to property `'` ! Mocksville,NC 27028 Subdivision Name:
Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 002563 A RNam :
I S zip:
**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 com liance with Article 1 I of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE l�ia PEOPLE 4 #PEOPLE/ HI y/ #SEATS INDUSTRIAL WASTE:Yes 06
LOT SIZE TYPE WATER SUPPLY �� /DESIGN WASTEWATER FLOW(GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH yr� ROCK DEPTH LINEAR FT.a
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
Do '//-)0
l 1�,r
r111"e)ell
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30-9:30 A.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS(336)751-8760.
OPERATION PERMIT � �,��� n/d
SYSTEM INSTALLED BY: �P �/I C '
1
AUTHORIZATION NO. 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 NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02102(Revised) �
f P.e'ttee' . �U 'VIE& NTY HEALTH DEPARTMEN XWPE�
77/rJ
Environmental Rf FORMATION
fName sHealth Section
P.O.Box 848
i .:DireC(ionS to property1 kr'i f J hlocksville,NC 27028 Subdivision Name:
r --Phone#: 336-751-8760
�f'e :jl _ Section: Lot:
AUTHORIZATION FOR
e y WASTEWATER
r�o SYSTEM CONSTRUCTIONa
AUTHORIZATION NO. �. A Road Name: Zip:
**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 Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
� l�`� �- 'r ' ` /..✓ ' r"� IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE ,oo#BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE f(1 t,#PEOPLE #PEOPLE/SHIFT _ #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY�(> DESIGN WASTEWATER FLOW(GPD) �� NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH,- LINEAR FT.
OTHERS/r
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT r
�161r J, J,-,
h nn� rfi Tei/1V75
01
�C0 r- C.
j sib
�C�- c�Z�i' Gress o el
**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:
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**T`HE 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 02102(Revised)
, 5 3
A414� TY HEALTH DEPARTMENTX�
,Name.'�s f Environmental Health Section PROPERTY INFORMATION
�, P.O. Box 848
Di4ections to prgperty Mocksville,NC 27028 Subdivision Name:
{-Phone#:336-751-8760
Section: Lot:
�
fir` t' AUTHORIZATION FOR WASTEWATER
SYSTEM CONSTRUCTION � —
AUTHORIZATION NO: o45 A Road Name; Zip:
**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 Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
'� A..r '� ,• 1F� {f! { �: IS VALID FOR A PERIOD OF FIVE YEARS..
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE</.,P r&', t#r,
PEOPLE J, #PEOPLE/SHIFT_L #SEATS' INDUSTRIAL WASTE:Yes or No
+ LOT SIZE TYPE WATER SUPPLY + t,- VDESIGN WASTEWATER FLOW(GPD) '�
NEW SITE REPAIR SITE
: f
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK____GAL. .TRENCH WIDTH ROCK DEPTH LINEAR FT.
OTHER r. ` / � � Z.
1 '
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROV�EMEfNT PERMIT LAYOUAT V' 4,� 1 4(f!r
�Js (Ilf
rF1�j /j
z
f' G
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPEt2TION,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 ..N
SYSTEM INSTALLED BY:
t
A_ '
r �
71
AUTHORIZATION NO. OPERATION PE&IT 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 TREATMEPtr AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAYB T KAS'A`
GUARANTEE THAT THE SYSTEM WILI3 FUNCTION SATISFACTORILY FOP,,ky GIVEN PERIOD OF TIME. � EN y r ev
DCHD 6ro2(Revised)' 604X
DAVIE COUNTY HEALTH DEPARTMENT
r Environmental Health Section
PO Box 848/210 Hospital Street �- z
Mocksville,NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACENT❑ REMODELING ❑ RECONNECTION• ❑
Name: t: ENL E 0, At5 / ti' Phone Number: Z , l � � ! / (Home)
7Mailing Address: F0 06 3 3�-, y16 Z ,.3 9il (Work)
01�eI221" ar7S A)C,
Detailed Directions To Site: w_eS4_ off- K •'
Property Address: _f576:7 - I ro i1
Please Fill In The Following Information About The Existin Dwelling.
� � r
Name System Installed Under: „�/lp /.,r� =&' A ,A(' Type Of Dwelling: CI-42
Date System Installed�Month/Day/Year):,//A 414 a a i i' Number Of Bedrooms:49je—Nwnber Of People
Is The Dwelling Currer}tly Vacant?`Yes ' No❑` -If Yes;.For HowA-png? 7 r. '
Any Known Problems?Yes 0 Nok I Yes,Explain:
Please Fill In The Following Information About The New Dwelling.
Type Of Dwelling:6MMCv-e,;A umber Of Bedrooms- Number Of4?eople: AtZ
Requested By: DateRequested: O
(S e) Qr. (�4 N^�Ju rte► �}- n G �n k
For Environmental Health Office Use Only
Approved Disapproved ❑
Comments: '7//'/
+ ,. 1 / �i�lli>r^ %../i ,l /� i/'" - ��'i %_,•'rc""� % i�/ ,— it "L; �j�i ' � �1; �
P .�C•Z
Environmental Health Specialist ���,''"'f�A� Date
"The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a i
guarantee(extended or limited)that the on-site wastewater system will function properly for any given period of time. I
Payment: Cash❑ Check[-Money Order❑ # 2 ) Amount: $ a O Date:
Paid By: -6.5 6 y:_�
�._.--. F- 5 i1•c-,(Received B �"-
Account #: ?7 Invoice #:
Parcel#: D700000200 Page 1 of 1
oP��
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Parcel#: D700000200 Account#: 82523982
Owner Information Tax Codes
OX BYRON CLAY ADVLTAX-COUNTY TT
200 US HWY 158 FIREADVLTAX-FIRE TAX
DVANCE NC 27006
Property Information Township
nd(Units/Type): 0.560 AC FARMINGTON
ddress: 5073 US HWY 158
Deed Information Local Zoning
Date: 02/2005 Book: 00593 Page: 0705
[Plat Book: Page:
Le al Description PIN
1.505 AC HWY 158 5872212902
Property Values
ulldin 159,77
BXF: 17,72
nu: 87,66
Market: 265,15CECC
ssessed: 265 15
eferred: cl
Sales Information
No. Book Page Month Year Instrument Qua[/UnQual Improved Price
00593 0705 02 2005 WD Qualified Vacant 80,000
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=1474962 6/15/2016