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AUTHORIZATION NO: 0941 DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Pee nittee ; ` . P.O. Box 848
;. a.
Name: (�;', Mocksville, NC 27028 Subdivision Name:
y �,�, Phone #: 704-634-8760
Directions. to property: �'ITSection: Lot:
AUTHORIZATION FOR
R
WASTEWATER' Tax Office PIN:4.1 -
SYSTEM CONSTRUCTION
Road Name: In 4 Zip:
**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 1 l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
�f IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTALIEALTH SPSP C� DATE ISSUED
' F � i Y`'�F ib-'rlri+F ,�.ryiy} ty �• .NY + ��.\ 7tA .... _ R '- ,�IC"YY`5ti 1 9 ai.!-,r t} •l 4'•Y:.1'.` ...�.'`[YAt ���i+7-
}/O
<}wDAVIE COUNTY HEALTH DEPARTMENT r�
IMPROVEMENT AND. OPERATION PERMITS : PROPERTY INFORMATION
Subdivision Name:
Directions to property: (1f_ J Section: Lot:
k f IMPROVEMENT r
PERMIT Tax Office PIN:#
r Road Name:1061 S Zip:
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the .
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF.SITE
- ; tom{ 1.::;• t,� , ,- } _,i: , �,° PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE Ali # BEDROOMS mss? # BATHS _ # OCCUPANTS _ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) \. NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE _GAL. PUMP TANK GAL. TRENCH WIDTH. �r� ROCK DEPTH ?V I/ LINEAR Fr.. LJO
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
"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 (704) 6348760.
OPERATION PERMIT s
SYSTEM INSTALLED BY: "
AUTHORIZATION NO. OPERATION PERMIT BY: DATE: l
V
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCT"
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.
DCHD 05/96 (Revised)
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMLTE Davie County Health Department Q i1
Environmental Health Section P.O. Box 848 1997
Mocksville, NC 27028
1 (704) 634-8760 I
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed0VI1T�G� I (9 . sol a e -S Contact Person -FGI rn' z P - Tics
+
Mailing Address c� �6 Jr 14wy W1 S. Home Phone�S'c1��
City/State/Zip Mockso,',e aldaq Business Phone 70`4 - iD3Ci ' 6`l1
2. Name on Permit/ATC if Different than Above
Mailing Address H wyy d L 5� City/State/Zip 1 V1�/1
3. Application For: [41Slie Evaluation [ ] Improvement Permit & ATC
4. System to Serve: [ ] House [1,40bile Home [ ] Business [ ] Industry [ ] Other
4- 1C.11
CkSVIII-c
N/Both
5. If Residence: # People J #Bedrooms # Bathrooms_Q []'Dishwasher [ ] Garbage Disposal
[,4 Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
-
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: L4'county/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [of Ro
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** SOF THE PROPERTY MUST BE
SUBMITTED WITH TJIIIS APPLICATION.
Property Dimensions: �X �.X r/a �XI a``�'y� ', WRITE DIRECT ONS (from ocksville) TO PRZZ
Tax Office PIN: ` #575z( - 37 - d 3 y ' (0o� herr 41 I !
Property Address: Road Name S0:5 Rwh 061 ►' `016, Se CIA
City/Zip I Vi M l lie IV, G a`L7Oag
If in Subdivision provide information, as follows:
Name:
Section: Lot #: '
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or
changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Representative of the Davie ounty Health Department to enter upon above described property located in Davie County and owned
by14arvev G 4I 67 to conduct all tes7-0
rce res as necessary to determine the site suitability.
DATE rT ' l ' 7 SIGNATURE r6' r lil d't
Revised DCHD (06-96)
THIS AREA MAY 13E USED FOR DRAWINC7 YOUR SITE PLAN:
t
::yS F v � .� - ��� - dr� .�.�}. r - ,� 1 ♦' f __e . y "�.Y. �-�� �"' x'i`I}R �t• ^,`�s
eta
;r
T A
a
I j
199
�qpc25-
G O N 265 O�6/
�d F
R 3
G3'd61 i b£ZE p- •pL� �i �+ ��� �'� .* 6 8. �bZj7�£�
z
li co r'�
L
55
co
ro
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£9z Z9'9i�- `�° O(�+ s her#si
s'oa �b�,..XoiL�C
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME DATE EVALUATED
PROPOSED FACILITY s//'! PROPERTY SIZE
SUBDIVISION ROAD NAME101�
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring i/ Pit Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
,L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
1 r
Texture group
Consistence
i
Structure
!G S
Mineralogy,
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: PS
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-90)
EVALUATION BY:
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
Mineralogy
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 #: N600000065
Davie County, NC - Basic Estate Search
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Parcel #: N600000065 Account #: 41356870
Owner Information
Buildin :
Tax Codes
BXF•
ONES MIKAEL& JONES TALMADGE P
nd:
ADVLTAX - COUNTY T
Market:
807 US HIGHWAY 601 SOUTH
ssessed:
FIREADVLTAX - FIRE TAX
Deferred
MOCKSVILLE NC 27028
Property Information
Township
Land (Units/Type): 0.870 AC
JERUSALEM
Address: 3805 S US HWY 601
Deed Information
Local Zoning
Date: 01/2000 Book: 00323 Page: 0657
Plat Book: Pa e:
Legal Description
PIN
1 AC HWY 601
58944000
PropertV Values
Buildin :
62,24
BXF•
nd:
16,37
Market:
78 61
ssessed:
78,61
Deferred
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
1 00323 0657 01 2000 WD Unqualified Improved 15,000
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/itsnet/View.aspx?prid=1462835 8/2/2016