2914 Hwy 601N' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 990002235 Tax PIN/EH #: 9900 -WW -2235
Billed To: Diane Childress Subdivision Info:
Reference Name: Location/Address: 2914 US Highway 601 N-27028
Proposed Facility Residence Property Size: see map
ATC Number: 2018A
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction 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 permit (in compliance with
Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type bt,\)AAq #People S #Bedrooms #Baths _
Dishwasher: e Garbage Disposal: ❑ Washing Machine: +J Basement w/Plumbing: ❑ Basement/No Plumbing: d
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: 13
Lot Size Type Water Supply Design Wastewater Flow (GPD) L4g 0 Site: New ❑ Repair
System Specifications: Tank Size GAL. Pump Tank GAL. Trench Width Rock Depth _ Linear Ft.2 ^ '
Other: J7LSTi21 i l0� LSC.
Required Site Modifications/Conditions: I, -SST -AL1- O.J C -4pr-3 WO,
IMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISERS) IF 6 "BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on the day of installation. Telephone# is (336)751-8760.****
72
Lo
Environmental Health Specialist's Signature: Fir Date: c5 jj 15
ej))
DCHD 05/99 (Revised)
Account #:.990002235
Billed To: Diane Childress
Reference Name:
Proposed Facility Residence
ATC Number: 2018A
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Tax PIN/EH #: 5820-29-1131
Subdivision Info:
Location/Address: 2914 US Highway 601 N-27028
Property Size: 7.6 Acres
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s) (in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems, Sectio .1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW O N IS ALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature. Date:���
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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.
4r
•90,
Septic System Installed By:
Environmental Health Specialist's Signature : Dater
DCHD 05/99 (Revised)
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�� AUTHORIZATION, NO: ,/ C3.`� �/� � DAVIE COUNTY HEALTH DEPARTMENT :
�' ` Environmental Health Section . PROPERTY INFORMATION `
Permittee's ,*'� � 1�,1 �. ', . P.O.'Box 8�18 � ,
' Name: ��-�� '�::'�i� 1 � T"�� ' t«�; Mocksville, NC 27028 �. Subdivision Name
�-:
Dire�ons to pmperty � �^:�v�'� Phone # 336 751-8760 '
� Section Lot:
AUTHORIZATION FOR
� �,� - �' . + ' f� WASTEWATER : -
�"�L"`�� �� ���, `_� SYSTEM CONSTRUCI'ION Tax Office PIN:#
�:,r.,�� �, . �c�r
Roac1 Name� �'� �`1t.�i�tG�✓��ip: � '�^�''1=��
**NOTE** lfiis Authorization'for Wastewater System Construction MUST BE ISSUED by the Davie Counry Environmental Health Section prior
to issuance of any BuildinglRermit�.'This Forn�/Authoriza'tion Number should be presented to [he DaVie County Building Inspections :,
; Office when applying,for $uilding Permi,ts.
(ln comµpliance with �� 71 'of G. Chapter;130A; Wastewater Systems, Section 1900 Sewage Treatment and Disposal Systems),
-`f � - �� f �^'^"� '° �***NOTICE*** THISAUTHORIZATION FOR WASTEWATER CONSTRUCTION
,�.....__._..'�--�,�'� �. - ��� � r'�.- :�. �- IS VALID FOR A PERIOD OF FIVE YEARS. :
.
ENVIRON EI� ,j�i'tTSPE IALIST,�; DATE SSUED
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. N ..` , � �°., � p `� �� DAVIE COUNTY HEALTH DEPARTMENT '
*N;, ; � r, ? ' IMPROVEMENT AND OPERATIOl� P�ER�ITS ;PROPERTY INFORMATION �� �
' . P�rmiftee's," ��,. � :St �' w�° ; ; ,. ; �. '
� �Name.'' a '�"'� l�'ti�� � . ;. �� � }„�'�� ' � � , � ��� Subdivision Nariie " �
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,�Directions to property'i l�- '� f, r � Secdon: Lot:
' ; ` a..� ,r - �. tV �." `. + �� 'II1�PROVEMENT s .
r II P
j�^',c�,� •;:;; t L,,-i�,'` ` PERMIT Tax.Office PIN:# - _
�' Roai�Nam�e� t�`~� 1n�: ;�'�..t..,�'�ip rf ���...4:�
�**NOTE** This Improvement Pernut DOFS NOT authorize the constiuction or installation of a septic tanlc system or any wastewater system. An
�;�,_ ALTTHORIZATION FOR'WASTEWATER SYSTEM CONSTRUCITON must be obtained frc�m this Department prior.to the '
��. : � ' . construction%installarion of a system or the issuance of a building pemut. � ` . � : ` � �
, `; (In compliance w th Article� l l of G.S. Chapter 130A` V�astewater Systems, Section .1900 Sewage Treahnent and Disposal Systems� �
'' ��. �' �--~'^'� �, ***NOTICE*** THLS PERMIT IS SUBJECT TO REVOCATION IF SITE
-� # ;...;� �-, . ,,; ( '��.,,,�;:; • � �/ , . ! : ,• �,,. , PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
Y' ENVIRONHTENT(�L ALTH SP�CIALIST' DA hSSUED , SI'STEM CONTRAGTOR MUST SEE TfIIS PERMTI',BEFORE
, : , . , � ' . . �7 ; : INSTALLING THE SYSTEM. ;
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' �. ' , r'.: .. . . �. . : .. �. , . . , � � ' . . �. . � ': �..w� ' ' .. �- , , ; . . . . . . ,
RESIDENTIAL SPECIFICATTON: BUILDING TYPE�rI # BEDROOMS �# BATHS _�,� # OCCUPANTS .'� GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILTTY TYPE # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WASTE: Yes or No
, . � : : ..
LOT SIZE ' TYPE WATER SUPPLY ��! r DESIGN WASTEWATER�FLOW (GPD) ��v ' NEW SITE REPAIR SITE �.�
. _ �, � I' " . + �
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �j.l ROCK DEPTH �� LINEAR FT. (��
; OTHER I ' � �Cj�l� �"LJ� �j�L '
REQUIRED SITE MODIFTCATIONS/CONDITIONS: t t V/�"�L� D� l �CI�V'"L '
n�tPRovE�rrrPExtvtrrLAYotrr�AppROUED EFFLUENT FILTER* �RISERtS) IF 6" BEl.�y� FINISFl��D GRAD��'
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'*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
. BETWEEN 8i30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALL}+,TION. TELEPHONE # IS (�� Yr����
t 336 ) ?51--8760
�� STALLED BY: ,
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AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
•*THE ISSUANCE OF THIS OPERATION PERMTf SHALL INDICATE THAT TI� SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I 1 OF G.S: CHAP'fER 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. . ,'•
\ �CHD OS/96 (Revised) . , . . . . _
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0 1, DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittee s
Name;�.(' #:,° s i'.,ild: Subdivision Name:
Directions to property: I t Section: Lot:
IMPROVEMENT
y
PERMIT Tax Office PIN:# -
�! Road Name ? 61'
J: **NOTE** This Improvement Permit DOES 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
constructionfinstallation of a system or the issuance of a building pen -nit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTALREALTH SPECIALIST DATE -ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPEiyy4r[i #BEDROOMS L"r #BATHS �Z #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIA SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS \ INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)xv NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH:/ ROCK DEPTH LINEAR FT.
OTHER
REQUIRED; SITE MODIFICATIONS/CONDITIONS: r»-
IMPROVEMENT PERMIT LAYOUT*APPROVED EFFLUE 4T F=ILTER* *RISER(S) IF b"BEI OW!"FIUISHED GRADE*
"
._x tr-q ► t-ZC.,
CVT 11 -L-A 111
U U f -k 17
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i
"*CONTACT A REPRESENTATIV OF THE DAVIE COUNTY HEALTH D PARTMENT FOR -FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A. . OR^i�t) �i 30 R A4. ,� Fj F STALLATION. TELEPHONE # IS W MY818 x
(336)751-8760
..............................
?0 .--
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE - r
WITH ARTICLE I 1 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 05/96 (Revised) "
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION iiName \ )01 C.Z.13 e � i cam 5S RE
(_ Phone Number: ` —` � � �a (Home)
Mailing Address: a �l 14 Its 1:h oT 7 I (Work)
Detailed Directions To Site:__) , -,-) YYl % 1 S "Yc) Y.
Property Address: 14 Lel S V t2 D I
Please Fill In The Following Information About The Existing Dwelling:
�4- T?wi �
Name System Installed Under: � �Gl �H t.1.1 le r af3 / Q $ Type `Of Dwelling: �DLA.S�=
Date System Installed(Month/Day/Year): q 1 Number Of Bedrooms: `' Number Of People:_
Is The Dwelling Currently Vacant? Yes F?'No ❑
If Yes, For How LongZ
Any Known Problems? Yes ❑ No � If Yes, Explain:
V-10 b2
Please Fill In The Following Information About The New Dwelling: o LV
Type Of Dwelling: Number Of Bedrooms: � Num` be f O -f People: S
Requested By: [.� Ile- L
Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments:
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 #: 7). Invoice #:
+, f Y'.
a M DAVIE COUNTY HEALTH DEPARTMENT
r
Environmental Health Section
c' PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
i
Name -M, e-� h I i r1 re:!5_4s Phone Number: ` -' 3 '- !7 (06 0 (Home)
`'Mailing Address: tel) US I -L o Ida) J V (Work)
Detailed Directions To Site:r 100, r)
ro�- 0 h a h- n r f k b -\-
Property Address: c2 q N lo -01
o..
Please Fill In The Following Information About The Existing Dwelling:
JD
F r Nie«� t-_ wi cLt,
Name -System Installed Under: �Cl _ (t l �e }� 13 o f S Type `Of Dwelling: iAoyL 4>
Date S stem Installed Month Da Year : �" I P Number Of Bedrooms: `1 Number Of People:
Is The Dwelling Currently Vacant? Yes &'No ❑ If Yes, For How Long?
Any Known Problems? Yes ❑ No If Yes, Explain:
S�- tt bQ
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling- Number Of Bedrooms: 4" Number Of Pgople '
V1_ 17
Requested By: I C zf F " " Date Requested -
(Signature)
Approved ❑
Comments:
For
Disapproved ❑
HealthOffice,Use Only,
J
EnyV: ,Qnmental Health Specialist Date
"The signing of this form by the Environmental Health StaffLs° in rio way intended; nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will'function properly for any given Mriod,of time.
Payment Cash ❑ Check ❑ Money Order ❑ # -; ' Amount: Date: l/
Paid By: Recef i'ved'By
Account #: JS'' Invoice #
l A.
r
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
i
Name -M, e-� h I i r1 re:!5_4s Phone Number: ` -' 3 '- !7 (06 0 (Home)
`'Mailing Address: tel) US I -L o Ida) J V (Work)
Detailed Directions To Site:r 100, r)
ro�- 0 h a h- n r f k b -\-
Property Address: c2 q N lo -01
o..
Please Fill In The Following Information About The Existing Dwelling:
JD
F r Nie«� t-_ wi cLt,
Name -System Installed Under: �Cl _ (t l �e }� 13 o f S Type `Of Dwelling: iAoyL 4>
Date S stem Installed Month Da Year : �" I P Number Of Bedrooms: `1 Number Of People:
Is The Dwelling Currently Vacant? Yes &'No ❑ If Yes, For How Long?
Any Known Problems? Yes ❑ No If Yes, Explain:
S�- tt bQ
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling- Number Of Bedrooms: 4" Number Of Pgople '
V1_ 17
Requested By: I C zf F " " Date Requested -
(Signature)
Approved ❑
Comments:
For
Disapproved ❑
HealthOffice,Use Only,
J
EnyV: ,Qnmental Health Specialist Date
"The signing of this form by the Environmental Health StaffLs° in rio way intended; nor should be taken as a
guarantee(extended or limited) that the on-site wastewater system will'function properly for any given Mriod,of time.
Payment Cash ❑ Check ❑ Money Order ❑ # -; ' Amount: Date: l/
Paid By: Recef i'ved'By
Account #: JS'' Invoice #
l A.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
{� Permit Number
Name t �1,
1,` 24// ;'�' A � Via• �'r' Date 2P4,
y" / �r'�� � � J 1 .,,may.. i ) , •l
Location .,f,,g�
Subdivision Name Lot No. Sec. or Block No.
Lot Size •f,;� House Mobile Home _ Business Speculation
No. Bedrooms =L__ No. Baths% No. in Family w
Garbage Disposal YES p NO _
apecifications/for System:
Auto Dish Washer YES NO C]
Auto Wash Machine YES NO
Type Water Supply �:•..""`. _�'�ti �5,/if:j'`r' -�,�'�
t
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by`�j'n�
*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 day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by j �"nU'��es 4-Scr-
moo 7z ia-
Certificate of Completion Date
*The signing of this- certificate shall indicate that the system describ d above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COMITY HEALTH DEPARTMENT
PERCOLATION TEST RESULTS
DATE ell
NA.*,iE
LOCATIO?1���
PINDINGS : HOLE PJO. /
-'1 ��i •��.:- /,:1�� ./`' sir-'�-', ,
r
LOT DIAGIWI
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- n
CONKITS /J
,24
By:
f
M
�_,_t_liD.AVIE COUNTY HEALTH DEPARTMENT
` s P. 0. BOX 57
MOCKSVILLE, N. C. 27023
(704) 634-5985
Statement for Septic Tank Improvement Permits.
and/or Site Evaluations
NAMEDATE ISSUED101
-L�-�--
ADDRESS PERIAIIT NO.
r
Explanation ofcharge&4Z ��,
AMOUNT DUECO SANITARIAN
PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT. ;:
Parcel #: F30000007802
Davie County, NC - Basic Estate Search
Basic Search Real Estate Search Tax Bill Search Sales Search 0
View Property Record for this Parcel View Man for this Parcel View Tax Bill Information
Parcel #: F30000007802 Account #: 19298550
Owner Information
Tax Codes
ULLER BARBRA JEAN
ADVLTAX - COUNTY T
148 HAPPY TRAIL
FIREADVLTAX - FIRE TAX
OCKSVILLE NC 27028
Market:
Property Information
Township
nd (Units/Type): 2.540 AC
CLARKSVILLE
ddress: 2914 N US HWY 601
Unqualified
Deed Information
Local Zoning
Pate: 02/1996 Book: 00185 Page: 0649
00162
Plat Book: 11 Page: 324
01
1992 WD
Unqualified
Le al Description
PIN
60 AC OFF HWY 601 2.540 AC
5820291131
Property Values
Buildin :
66,4
BXF•
23,76
Land:
31,67
Market:
1218
ssessed:
121 89
eferred•
1987 WD
Sales Information
No.
Book
Page
Month
Year Instrument
Qual/UnQual
Improved
Price
1
00139
0806
09
1987 WD
Unqualified
Vacant
5,000
2
00162
0272
01
1992 WD
Unqualified
Vacant
0
3
00185
0649
02
1996 QC
Unqualified
Vacant
0_
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
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Davie County Web Site
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=1490657 8/9/2016