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4652 Hwy 601NDavie County Health Department 4;) �8 _1 Environmental Health Section ! P.O. Box 848 210 Hospital Street ( O U 1A .1t Courier # : 09-40-06 1911 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION" Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Name: &b4✓ Phone Number (Home) Mailing Address: (Work) Email Address: Detailed Directions To Site: Property Address: %5z �lS l or ml N Xo7e�lsolk- N Ci z7oa Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes --o If Yes, For How Long? Any Known Problems? Yes If Yes, Explain: ��• t� r Please Fill In The Following Information About The NEW Facility: Type Of Facility: Q Number Of Bedrooms: Number of People Pool Size:ge Size: Other: Requested B Date Requested: ignature) For Environmental Health Office Use Only pprove Disapproved Comments: Environmental Health Specialist, Date: *The signing of this form by the Environmental Health Stdff 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 #: CDP-# l Iyi 3o Invoice #: Date: Davie County Health Department 4;)�'8 j�.t Environmental Health Section i P.O. Box 84S.'. t ti 210 Hospital Street Courier # 09-40-06 1911: Mocksville, NC 27028 46 Phone: (336) - 753 - 6780ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 (Check One) Replacement Remodeling Reconnection Name: Phone Number (Home) Mailing Address: (Work) . Email Address:' Detailed Directions To Site: ' f/74PQ�V Property Address: Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: tl Type Of Facility:-Ti-Fan-du f Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes ° fiT If Yes, ForNow Long? � ` % Aj .C%tie JE Any Known`Problems? Yes 0 Nof If Yes, Explain: / ` Please Fill In The Following Information About The NEW Facility: Type Of Facility: a ti I 174r, /`6- ` Number Of Bedrooms: Number of People _A Pool Size: ge Size: Other: equested B Date Requested: �ignare) For Environmental Health Office Use Only PProve Disapproved i' Comments: . Environmental Health Specialist Date: -a&,& O/ *The signing of this form by the Environmental Health St f is in'no way intended, nor should be taken as.a guarantee (extended or limited) that the on-site wastewatersystem will function properly for any given period of time. Payment: Cash Check Money Order # Amount:$ Date r--:7- , Paid By: Received By:' Account #: Invoice #: C�Q lNl 36 464 Tel 012 l 4330 }' = 1 560CD ,pP"IGv Jc x{5.16 ll. L r + 1 I `V N =1636 -- - CV +�. OPex�C° All data is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Implied C�0 r warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of U N1 \\\ Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of Prin + leV,.t .JaCI O2, 2013 the use or Inability to use the GIS data provided by this website. v ;-0 DAVIE COUNTY HEALTH DEPARTMENT : h:3) ILA—�:3�� +.: Environmental Health Section PROPERTY INFORMATION ,.. }. P.O. Box 848 P P y Mocksville, NC 27028 Subdivision Name: Din ecdons to ro ert jC.. �� ` t >° Phone #:336-751-8760 Section: Lot: AUTHORIZATION: FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTIONIJ - - -AUTHORIZATION NO: 2259 A Road Name ip I� . **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 30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ' IS VALID FOR A PERIOD OF FIVE YEARS.' ONIV�ENTYAL F7EL'fH SPECl/jLIT �t DATE 1 SUED RESIDENTIAL SPECIFICATION: BUILDING TYPE�M { # BEDROOMS 3 # BATHS .Z # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No rt n �'"jam LOT SIZE ( +'�\W TYPE WATER SUPPLY VlA1V W DESIGN WASTEWATER FLOW (GPD) �ys�" NEW SITE - REPAIR SITE (' d �r SYSTEM SPECIFICATIONS: TANK SIZE .- GAL. PUMP TANK GAL- ,TRENCH WIDTH 3 ROCK DEPTH Z LINEAR FT.' I 0 � ,. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: GPT&q + 42b F t LL ' t tT AJ LOLJ A i 10 C -1 .,j IMPROVEMENT PERMIT LAYOUT At,. EP 'ExS�►►�(, 't j c��t l� t� (3 Q� 2 t-1 ouSu If 0.{, Cn ;L **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 n SYSTEM INSTALLED BY: ` tr ` +u 7 -F N J L� �q z� AUTHORIZATION NO. �� ` AOPERATION PERMIT BY: DATE: A in "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT TH SYS M DESCRIB D ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE AT E AND DISPOS L SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR " IVEN PERIOD OF TIME. . DCHD 02/02 (Revised) 0IIN130 �ri -74' GM 4 - � .Id ANz 3, „E- 3:. lx , ye �..y zL` SYR 1 '� ' , VP , 'S Cal Mk k v 1 M � 1 3 3 ,� .,.. 3�.aai• 'S a�fax 4 ��' '' �s ffi1ii� :.€I� �'�>� ,, �� k m:." • • ^ k �b� k . E miv, ,740, m xR+ .. r4 .,b ri � >.;ti xp w „ ar 4 .ra'r F ✓ £ .44 u s� ,h r„"t x , :fir y » x « OF a a ro,p, a$ � s w a ti J01% rW7, k •:dx» $d°��s� �« ,+. f `Y' „ wa '`ao � ar r k /�.'».:d� a e . 'a 'Mob,y�S-6 , MY5 �Y� I � <�'>,.,� �`r,: � iar' I 1�.1}'.su r.^: ,.� ,, �jk � ��x�"a "$•Kr k .�;. Ela �� & �' �� y k & /ym„ :A i 3�,M35 y,3aE �' l➢n''� �"'9 1m /„ M O s _ �i ry a,t;,,': � � �ri' �.�,• sv�r��+ a y � 'k/ ki�» W • DAVIE COUNT' HEALTH DEPARTMENT 1) J IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION �U' *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanitary Sewage Systems Permit Number Name `i Q C� 5 a - _ Date J 1- Lt N° 7 4 1 7 Location 5 ., :.,� t Subdivision Name Lot No. Sec. or Block No. r Lot Size -� �' " House Mobile Home Business _— Industry No. Bedrooms _. No. Baths _ No. in Family_ Public Assembly Other Garbage Disposal YES ❑ N0 ❑ Specjfications for System: Auto Dish Washer YES [3 NO E3I co Auto Wash Ma :hive YES Q . NO ❑ Type Water Supply *This permit Voidif sew eiicribed be o is not installed within 5 years from date of issue. This permit is subject t revocation if site plans or the intended use change. G,v. Improvements permit by *Contact a representative of the Davie County Health Dgartment for final inspection of this system between 8:30-9:30 A.M., . 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagra System Installed by \"\, k, Certificate of Completion Date r 1 'The signing of this certificate shall indicate that the system described 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 DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) DIRECTIONS TO SITE l06 / PV d r7"l NUMBER SION NAME 76 A 9 LOT #, r(E!' d DATE SYSTEM INSTALLED ��� NAME SYSTEM INSTALLED UNDER TYPE FACILITY Se— NUMBER BEDROOMS NUMBER PEOPLE SERVED :2- TYPE WATER SUPPLY /1SPECIFY PROBLEM OCCURRINGT���rS 2� //la, r_Po vn--De- d �k OLIL k S q I ✓l -n a _j /G . _.C:1 __j DATE REQUESTED "� -�7 INFORMATION TAKEN BY /Z&S This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT 4,72.- Rev. 1193 If Parcel #: C300000045 Davie County, NC - Basic Estate Search Basic Search Real Estate Search Tax Bill Search Sales Search View Propertv Record for this Parcel View Mao for this Parcel View Tax Bill Information Parcel #: C300000045 Account #: 7340000 Owner Information BF: Tax Codes Land: Land: BLEDSOE BUDDY C & BLEDSOE BETTY M Market: ADVLTAX - COUNTY T ssessed: 652 US HIGHWAY 601 NORTH eferred• IREADVLTAX - FIRE TAX MOCKSVILLE NC 27028 Property Information Township Land (Units/Type): 1.080 AC CLARKSVILLE ddress: 4652 N US HWY 601 Deed Information Local Zoning ate: 02/1988 Book: 00142 Page: 0075 Plat Book: Page: Legal Description (-- PIN 91 AC HWY 601 N 5823209920 PropertV Values uildln 69,20 001 BF: Land: Land: 19 220 Market: 88,42 ssessed: 88,42 eferred• Sales Information No. Book Paye Month Year Instrument Qual/UnQual Improved Price 1 00142 0075 02 1988 WD Unqualified Improved 0 View Property Record for this Parcel View Map for this Parcel View Tax Bili Information « Return to Basic Search Page 1 of 1 o11 rF oclotrll-s 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=1457448 8/9/2016