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ff DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
' *NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewa a Systems Permit Nu ber
Na eI/c'/';; ;<ri>' �� �- Date. NO
� LOC tion ���� div �/,,•�rr-%"" .1''`rr": t''s'�'` t D.°:i' ..� 1��` '`err'`
Subdivision Name Lot No. Sec. or Block No.
Lot Size fJ''� House Mobile Home Business — Speculation
No. Bedrooms :_s No. Baths No. in Family _
Garbage Disposal YES '❑ NO Specifications for System:
Auto Dish Washer YES I' NO ❑ -,c
Auto Wash Ma thine YES p^- NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
4 g
M. �a G,f . .........e
t'
Improvements permit by
*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 Installlation �agi
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System Installed by –T-1171� Z�
___-:=_____ I I r
Certificate,of.Completion Date -
*.The signing of this certificate shall indicate that the system described above hasibeen 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Y \moi u
I� Davie County Health Department • Z 1993 -j„ Environmental Health Section
` t P. O. Box 665 --- ___
O
UP op NC 27028
Application/Permiyyt��Requested By /4 A(AK, C . 5 haue/2
Mailing Address 10 BOK Y 3- cbOwnSU, (le N•}, 1375S (09-) $a1C51g mdcksdi t'lp, A).C. 270.
Home Phone (60 �� 3�3- 5�7R % e j �d �� a �r�-a7ya Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve:
❑ Business
EX General Evaluation
❑ House 59 Mobile Home
❑ Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People �-
No. of Bedrooms 3
No. of Bathrooms
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply: GJ Public
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Private
8. Property Dimensions % ACR&S Sewage Disposal Contractor
0 Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
® Washing Machine
® Dishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Q No
If yes, what type?
❑ Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
ts0 4A
"CO UhJry h,
1"te) �f-n
on 6o 1� abarn*/es f4q.5f 5),WsY e6rners"-f4s74 ffi6
iha(Ver ah l� f(ShGue� an `n,411h6x)
yva,-4 g alwo A10- - Jaw
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 54 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (12-90) 1
j DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME .,�/fJZj DATE EVALUATED _'jlll�eE
ADDRESS
PROPOSED FACIILTY
Water Supply:
Evaluation By:
PROPERTY SIZE J rw('
LOCATION OF SITE
On -Site Well Community
Auger Boring ✓ Pit
FACTORS 1 2 3 4
Landscape position - J-
Sloe Z 21,11
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH/ -
Texture group G
Consistence r
Structure �%✓� /:
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD(01-901
Public
Cut
EVALUATED BY: zk
OTHER(S) PRESENT:
LEGEND
Landscape Position
R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope
CC -Concave slope CV -Convex slope T -Terrace FP -Flood plain H -Head slope
Texture
S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt
SICL-Silty clay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR-Very friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm
Wet
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic
Structure
SC -Single grain M -Massive CR -Crumb GR, -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralolty
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon- Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors
with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
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Parcel #: N60000004901
Davie County, NC - Basic Estate Search
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Parcel #: N60000004901 Account #:64634500
Owner Information
Tax Codes
ADVLTAX - COUNTY T
READVLTAX - FIRE TAX
HAVER ARTHUR C & SHAVER BONITA F
693 US HWY. 601 SOUTH
MOCKSVILLE NC 27028
BXF:
9,00
Property Information
Township
(Units/Type): 4.510 AC
Eess:3693 S US HWY 601
JERUSALEM
ssessed:
50,79
Deed Information
Local Zoning
Date: 03/1986 Book: 00130 Page: 0455
Plat Book: Page:
Le al Description
PIN
K.50 AC HWY 601
5754286869
Property Values
Building:
BXF:
9,00
Land:
4179
Market:
50 79
ssessed:
50,79
Deferred:
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
1 00130 0455 03 1986 WD Qualified Vacant 11,500
View Property Record for this Parcel View Mau 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=1466775 7/29/2016