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