1931 Hwy 601SDAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR OPERATION PERMIT
Account #: 990004119 Tax PIN/ EH #: L502OA0008
Billed To: M & M Construction Subdivision Info:
Reference Name: EXPANSION PERMIT Location/Address:' 193TUS Highway 601 S-27028
Proposed Facility: Residential Expansion Property Size: 1 -35 -acres
.ATC Number: 5894
**NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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.
System Type:--— S.T. Manufacturer e 1 Yl Tank Date_ Tank Size
Pump Tank Size / Bedrooms_
System Installed By: c Z O, Inspector#: Date-_W2713011t
GPS Coordinate:
Environmental Health Specialist:
DCHD 11/06 (Revised)
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DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780 / Fax # (336)753-1680
REPAIR IMPROVEMENT PERMIT
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
Account #: 990004119 Tax PIN: EH #: L5020A0008
Billed To: M & M Construction Subdivision Info:._:.
Reference Name: EXPANSION PERMIT LocationiAddrosS: 1931'US Highway 601 S-27028
Proposed Facility: Residential Expansion Prbpert Size: =:,1.35�acr
Site Type: Repair xpansion ( )
ATC Number: 5894
**NOTE** This IP/ Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental
Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A
Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS IP/ AUTHORIZATION TO
CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat
or the intended use change.
Residential Specifications: # Bedrooms i # Bathrooms_ # People Z Basement❑ Basement plumbing
Non -Residential Specifications: Facility Type # People # Seats
Square Footage(or Dimensions of Facility)
Lot Size '�- O -C_ Type of Water Supply: KLCounty/City ❑Well ❑Community Well
System Specifications: Design Wastewater Flow (GPD) *0 Tank Siz A n 13AL. Pump Tank GAL.
Trench Width 3f� Max. Trench Depth � Rock Depth_ Linear Ft.ZC5'/o
Site Modifications/Conditions/Other: f)
Contact the Davie County Environmental Health Section for final inspection of this system between
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Davie County Health Department
'(0N Environmental Health Section : ,
P.O. Box 848
C�
s„ 210 Hospital Street
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: MA 661V'_5L_NCh0fj Phone Number (Home)
Mailing Address: (Work)
Email Address:
Detailed Directions To Site
Property Address:
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: /n. Type Of Facility:
Date System Installed (Month/Date/Year): lf' Number Of Bedrooms: V Number Of People:
Is The Facility Currently Vacant? YesNo If Yes, For How Long?
Any Known Problems? Yes 0If Yes, Explain:
Please Fill In The Following Information About The NEW Facility: /J
Type Of Facility: % D /_ZQ O /y` Number Of Bedrooms:_ Number of People_
Pool Size:
Requested By:
Size:
Other:
Requested: 21Z 12—
For
Z
For Environmental Health Office Use Only
ep
rov Disapproved ff ,,
Comments: 111 6)m1 to ("A tlooi olRkit) ('9T PA'P6P 1 f1cn /t
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 #: ��/ Invoice #: gaZ�l
Date:
m
Davie County Health Department
1836 Environmental Health Section
A _Al P.O. Box 848
s.' 210 Hospital Street
O Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION a Fax: (336) - 753-1680
(Check One) Replacement Remodeling' Reconnection
Name:�'� 1 i 1 �� /YS�i�t U /d!" Phone Number (Home)
Mailing Address: (Work)
Email Address:
Detailed Directions To Site: S. .g? 't 0! [� * f li
Property Address. - -
STING Facility:
Please Fill In The ollow�
ng Information About The EXISTING y
Name Syste I/tt d Under: - Type Of Facility:
Date Sy to Installed (Month/Date/Year): Me Number Of Bedrooms: V Number Of People
Is The Facility Currently Vacant? Yes No If Yes, For How Long? - r C
Any Known Problems., Yes No, If Yes, Explam _
PleaseTill In The Following Informut �ori"AbOut TIie4NEW F`a(c'
it
Type'Of Facility: / n %� " - ---• Nilrabe f Bedrooms: Number of People pC
Pool Size: Garage Size: Other:
Requested By: %�%/L<% / /?"ice �— '' Date Requested: 21
(Signature)
s
For Environmental Health Office Use Only
APProv Disapproved /
Comments:Tf 7 �7/T ti(.lt d tt, (`'t � 60"i lel F' O/)
1
Enviroi�mental.Health Specalis ✓ s Date:l/%
r l 1
*The signing of this form by the Environmental Health
' Staff is iri-no yvvay iriteyded, n& should betaken as a guarantee
- , +! t �."j �� 1.4i �C �' Jr�rR t -pro
I f�' `A'
4 (extended or limited) thatIthe on-site wastewater system.will functiJ properly for any given pendd "of,time.' c'
Payment: Cash a-,,-Check Moriey40rder # Amount:$%Qn .d� Date:
rf
Paid By ,; k { i ` Received By:
Account #y+y�� J Invoice
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/ Fax (336)753-1680
Application For: ❑ Site Evaluation/Improvement Permit ❑ Authorization To Construct (ATC) ❑ Both
• Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE -REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name C'p �j'� ioYl CP, �✓1 n Contact Person :3�yl i!'G�
Address arj2; t le al Home Phone 336 -Q9 �7 U
City/State/ZIP/�I,// G�LSV, "/� -/Vc 2 7a2 Business Phone
Name on'Permit/ATC if Different than Above
Mailing Address
rKvrP,K I Y I Nt' VKIVIA I WIN Tivate Housen acility corners I� Iaaeed
NOTE: A survey plat or site plan must accompany this application. Included: ❑ Site Plan ❑Plat(to scale)
(Permit is valid for 60 monthf /with site plan; no expiration with complete plat.)
Owner's Name S %t er /a �C trGtGr Phone Number '�34� 6
_513 —/I Z'3
Owner's Address I 3 / gol S City/State/Ziy,2WI /VC 2 70ZQ
Property Address City ilei% s-ilt /'49
Lot Size Tax PIN# 46oZly 000? J/
Subdivision Name(if applicable) Section/Lot#
Directions To Site:
If the answer to any of the following questions is•"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site?
_Yes
_No
Does the site contain jurisdictional wetlands?
_Yes
_No
Are there any easements or right-of-ways on the site?
_Yes
No
Is the site subject to approval by another public agency?
_Yes
No
Will wastewater other than domestic sewage be generated?
Yes
No
IF RESIDENCE FILL OUT THE BOX BELOW
# People # Bedrooms # Bathrooms Garden Tub/Whirlpool ❑Yes ❑No
Basement: ❑Yes ❑No Basement Plumbing: ❑Yes ❑No
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: ❑Conventional ❑Accepted ❑Innovative ❑Alternative- ❑Other
Water Supply Type: County/City Water .❑ New Well ❑Existing Well ❑ Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes ❑ No
If yes, what type?
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use
changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and corners and
locating flag 'jg or sta ing the house/facility location, proposed well location and the location of any other amenities.
roperty owne s or owner's legal representative signature Site Revisit Charge
2 Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ❑No Account #
Revised 11/06 Innvoice #
GOMAPS - Davie County NC Public Access
4 �-tel �"�`��"•�� �' � ,
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U o 143ft �
***WARNING: THIS IS NOT A SURVEY!*** Friday, January 6 2012
This map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map.
WATERSHED -STRUCTURES
WATER -BODIES
a
COUNTY_BOUNDARY
ADDRESS
DRIVES
i
STREETS
RAILROAD -CENTERLINE
L�I
PARCELS
-�
CITY -LIMITS
BERMUDA RUN
EDCOOLEEMEE
ElDAVIE
COUNTY
MOCKSVILLE
nccounties
DAVIE
<all other values)
***WARNING: THIS IS NOT A SURVEY!*** Friday, January 6 2012
This map is prepared for the inventory of real property found within this jurisdiction, and is compiled from recorded
deeds, plats, and other public records and data. Users of this map are hereby notified that the aforementioned public
primary information sources should be consulted for verification of the information contained on this map. The
County and mapping company assume no legal responsibility for the information contained on this map.
r
Parcel #: L502OA0008
Davie County, NC - Basic Estate Search
Basic Search Real Estate Search Tax Bill Search Sales Search 0
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
Parcel #:L5020A0008
Account #:8304442
Owner Information
BXF:
Tax Codes
Land:
IDD SHEILA P
Market:
ADVLTAX - COUNTY TA
�FIREADVLTAX
ssessed:
1931 US HIGHWAY 601 S
eferred:
- FIRE TAX
MOCKSVILLE NC 27028
Property Information
Township
nd (Units/Type): 1.350 AC
JERUSALEM
ddress: 1931 S US HWY 601
Deed Information
Local Zoning
Date: 11/2014 Book: 2014E Page: 1119
Plat Book: 0002 Page: 086
Legal Description
PIN
LOTS 43-50 + 67-68 FOSTER
5746180262
Property Values
uildin
85,75
BXF:
77
Land:
19,51
Market:
106 03
ssessed:
106,03
eferred:
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
L 00821 0132 03 2010 WD Unqualified Improved 123,000
Z 2001E 0181 07 2001 WL Unqualified Improved 0
3 2014E 1119 it 2014 DC Unqualified Improved 0
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
r< Return to Basic Search
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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/itsneWiew.aspx?prid=1477251 8/9/2016