3311 Hwy 601NQ P1836j�
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Phone: (336) - 753 - 6780
Davie County Health Department
environmental Health Section
P.O. Box 818
210. Hospital Street
Courier #: 0940-06
Mocksville, NC 27028
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement . Remodeling Reconnection
Name: ea'A -C' It S C"-""A"y Phone Number y .G a - a (...;I 5
Fax: (336) - 751- 8786
(Home)
Mailing Address: 3 :3 I i N «, h v I N c• r,l V- (Work)
Detailed Dimntinnc To Site: i -i CAI �� (� U (� U r 4 (- c .! to r c, \[ 3 -y ��� i ( e IV u'r •-
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Property Address:5. 11V 9 y J ��7 t�
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under.�, f r /Y> S u I Type Of Facility: YJ S -f
Date System Installed (Month/Date/Year): Qe�a1,� VIP Number Of Bedrooms: .� Number Of People:
Is The Facility Currently Vacant? Yes No If Yes, For flow Long?
Any Known Problems? YesNo If Yes, Explain:
Please Fill InThee Followhrp_ Information About The NEWP Facility:
Type Of1 Facility: �r x.11 Number Of Bedrooms: Number of People
(Signature)
For Environmental Health Office Use Only
App Disapproved
comments: ��c� �PPVO 7sea l tJ� so ��A� .
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Environmental Health Specialist bate:oil Irle
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(C11tC1111GC1 Uf ltlltltell) Witt.fl tilt -site wasLeVVater SyJLelll,will luliUt1V11 vi-tivolly lot. ally givull Volluu UI tittle.
Pavment: Cash (C/hecN Monev Order # /Z'/
l(iJ. 0 d Date.
A rronnt #- `6{3 15-& Tnvnini- #- 7��
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Permittee' ` DAVIE COUNTY HEALTH DEPARTMENT
Name: ' � r'fu ±M6nEnvironmental Health Section PROPERTY INFORMATION
P.O. Box 848
Directions to property u iVlocksville, NC 27028 ,Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
,�► �s iil (Ptd WASTEWATERZ7
6SS/�
SYSTEM CONSTRUCTION Tax Office PIN/::# 9 b
AUTHORIZATION NO: 002863' A Road Name:
**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 I 1 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.
ENVI ONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS c� # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE 1' 7 # PEOPLE/SHIFT Z -' # SEATS "M INDUSTRIAL WASTE: Yes 00
LOT SIZE 15 OTYPE WATER SUPPLY U/C I DESIGN WASTEWATER FLOW (GPD) ltd"y NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 1 O00 GAL. PUMP TANK N �� GAL. TRENCH WIDTH 3 ROCK DEPTH 2 �LINEAR FT. 2y�
OTHER !T/ IAGG Ohl 5��1�Wl(W Y�G�i� J %!/�tl�L1 ` %%/Y/ TSG% /Yl/7�- J,' (�%� t!R/<f!/!T•Ow
REQUIRED SITE MODIFICATIONS/CONDITIONS: �t?i1� h a c �l1 �S �,G�'F i t • �� 01�\1A w� U'' ' l
IMPROVEMENT PERMIT LAYOUT
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10
Al to ja N�
1M �2 K S S; 14 '�""".-°- (p O I fJ .r—�j S ►� Gi k:11 V � 1 I L
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 \. . W 6 €s' ` n
fl �, JL ` `` SYSTEM INSTALLED BY: 134 M
01
C
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AUTHORIZATION NO. "v OPERATION PERMIT BY: / DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02102 (Revised) ��O n
je 9y,"".+! .• v
Pel'mi(tee's' DAVIE COUNTY H ALTH DEPARTMENT
1-6ame.' CL Il - Environmental Health Section PROPERTY INFORMATION
" *t- 1 1 P.O. Box 848
irections to -D� .� . S 1 l W f 11
,�? PY• P �� - Mocksville,_NC 27.028_. __..,Subdivision Name:
t Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
�61 HS Ulul) laol WASTEWATER Tax Office PIN:
L - - ft7q
SYSTEM CONSTRUCTION
AUTHORIZATION NO: 002863 A Road Name: Lf �/
mlmzkZip: 02
**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
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVI ONMENTAL HEALTH SPECIALIST DATE ISSUED
,b
. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE 1 ' y # PEOPLE/SHIFT 7 ' y # SEATS /V//4 1N61JSTRIAL WASTE: Yes or(9
LOT SIZE OC ' TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) IZa NEW SITE REPAIR SITE
\t .
SYSTEM SPECIFICATIONS: TANK SIZE X111GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 2 LINEAR FT. Z L a
OTHER /1i'7�dcc �,/d 51//b Al /���)�p/ra:� I•%nAl- .i/��</✓7/_��yr�a. .Jr c�/� l���r/y7<'db��
REQUIRED SITE MODIFICATIONS/CONDITIONS: r0� ha c 1t C: S1 : sc �'' • p'� �.. l n },yt L A
IMPROVEMENT PERMIT LAYOUT
AV
lot
N ray,) APA
` 1'Y� rC K S V � 1 t. 'r"'�„'-. /� """'•� 1 la C � e: it U-� 1 I � ` .
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
1 SYSTEM INSTALLED BY:ell
µ sour (t
w Ci 3 �.jtil
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T .
AUTHORIZATION NO. (�3 OPERATION PERMIT BY: -�� DATE: ((( CCC •••///
*"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 07102 (Revised)
1� N�t� �e�tANC
NAME �Qur
9xbk-11tqj 1�17Z
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
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PHONE NUMBER &7q' ZIn 2S—
_ADDRESS cS31I US IWI &0I lV • SUBDIVISION NAME
/J LOT #
DIRECTIONS TO SITE 141) &0/ / y '
) emm`l �i" paodtcs A1
DATE SYSTEM INSTALLED /q&0 NAME SYSTEM INSTALLED UNDER a i9fm
TYPE FACILITY RIo neer NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY e SPECIFY PROBLEM OCCURRINGJ welp,�f'/e-
:IWO MOOS I -zea CII(!�/e� ,
DATE REQUESTED ��_7_Ol� INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my
SIGNATURE OF OWNER OR AUTHORIZED AG
Rev. 1/93
that I understand I am responsible for all charges incurred from this application.
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GoMAPS - Davie County NC Public Access
Davie County, NC - GIS/Mapping System
Page 1 of 1
4�aV1
Click Here To Start Over Quick Search: (County ID c
fictive Layer Ouse,%ap T,ps GIS
��U tI� D PARCELS (Map Tips Available) *+
I__ Map Layers I Results I
http://maps.co.davie.nc.usIGoMapslmap/Index.cfm?mainmapservice=gomaps&CFID=4129... 5/5/2008
Parcel #: E300000097
Davie County, NC - Basic Estate Search
Basic Search Real Estate Search Tax Bill Search
Sales Search I�
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
Parcel #: E300000097 Account #: 8302322
Owner Information
Building:
Tax Codes
BXF:
RTER DAVID COLEMAN
E,1717
Land:
ADVLTAX - COUNTY T
Market:
LONGTOWN ROAD
ssessed•
FIREADVLTAX - FIRE TAXONVILLE
Deferred:
NC 27011
Unqualifled
Vacant
Property Information
Z
Township
Land (Units/Type): 3.580 AC
08
CLARKSVILLE
ddress: 3311 N US HWY 601
Improved
350,000
Deed Information
00457
Local Zoning
Date: 06/2013 Book: 00929 Page: 0603
2002 WD
Unqualified
[Plat Book: Page:
0
1,
Le al Description
0178
PIN
14.683 AC HWY 601
Unqualified
5811948274
500
Propertv Values
Building:
127,7901
BXF:
Year Instrument
Land:
15594
Market:
28373
ssessed•
28373
Deferred:
1992 WD
Sales Information
No.
Book
Page
Month
Year Instrument
Qual/UnQual
Improved
Price
L
00166
0409
12
1992 WD
Unqualifled
Vacant
25,000
Z
00343
0069
08
2000 WD
Unqualified
Improved
350,000
3
00457
0187
12
2002 WD
Unqualified
Improved
0
1,
00594
0178
02
2005 WD
Unqualified
Improved
500
i
00929
0603
06
2013 WD
Unqualified
Improved
0
i
00775
0390
11
2008 WD
Qualified
Improved
294,500
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/itsnettView.aspx?prid=1489660 8/9/2016