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AUTxoRizA�ioN �o �'� � ��,� �DAV�E .COUNT.Y.��:HEALTH DEPARTMENT �.:'; � � , , ' �. � � ,' �. `
� ,..,
; ;� : -,, ,: . .
�, � y ` Environmental Health Section -. PROPERTY INFORMATION `
i FemSi�'tee s• r � � � P.O. Box 848
,; � , ,
.� � ,�r , . ,
Name `� tK�.. '�, �.�" Mocksville; NC 27028 Subdivisiop Name
� � ` � ` Ptione # 336=751-87b0
_ Directions to propetty � '�� f���s� � ��+'' 1 �� `i��=� � � � _ - , : �. � Section: � � `Lot �
� AUTHORIZATION FOR � �. " � � '
` � "'` ��, � ��� � 7��. R�+�.!}`� , �`''� I-�r'�,�+'��- VVASTEWATER ' . ; Tax Of�ce PIN:# � � _ ` ��' _ �«�� `. .'
� SYSTEM CONSTRUCTION , ,
Road Name: ��,� ����• Zip: �^7��
T**NOTE** 'I'his Auth�riz'ation for;Wastewater System Constniction MUST BE jSSUED by the DaVie County Environmental Health Section prior
� ' to issuance of any Building~Rermits. This FormlAuthorization Number should be presented to the Davie Counry' Building Inspections .
f' =' Office when applying for Building Permits: ' � ' -
(In compliance with Article 11 ' f G.S. Chapter 130A; Wastewater Sysiems, 5echon .1900 Sewage Treatmenf and Disposal5ystems) ;:.
�-
� �"" ,' ` **�NOTICE**.* T�-IIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
t,.;� �
.� ;`': �..�,� ' t.....,. I: 1� ]� .' I5 VALm FOR A PERIOD OF FIVE YEARS
�I�VIEt�U � AC��HEALTH'�PE AL�[ST � ; � �pATE' SSUED ��� �
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APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMI ? gr U U
Davie County Health Department
Environmental Health Section FEB 16
P.O. Box 848 NEW PHONEE-H
ER:
Mocksville, NC 27028 EFFECTIVE MARN MENTALHEAL
(704)634-8760 336751- DAVIECOUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
r
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed Contact Person i
Mailing Address Home Phone ,
City/State/Zip . S V 4 . G � % Business Phon
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: [ ] Site Evaluation [ ] Improvement Permit & ATCth
4. System to Serve: [ ] House F-Nobile Home [ ] Business [ ] Industry [ ] Other
5. If Residence: # People # Bedrooms_ # Bathrooms [ j<Dishwasher [ ] Garbage Disposal
/]"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: krcounty/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes J;, ' o
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***QC-TVW OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions: ' ` �71?.�l
RECTIONS (from Mocksville) TO PROPERTY:Tax Office PIN: # �;/o d / . S. /' 45 L i Ai 1�AAgzv ,
Property Address:._". Road am e J lnUfU
,
City/Zip ;
If in Subdivision provide information, as follows:
,
,
,
Name: ,
Section: Lot #:
,
,
,
D
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 County Health Department to enter upon above described property located in Davie County and owned
by ,��llv 1 ft�Y/ to conduct all testing procedures as necessary to determine the site suitability.
DATE SIGNATURE—A&
& -�
Revised DCHD (06-96)
THIS AREA MAY BE USED FOR DRAWING JOUR SITE PLAN:
• DAVIE COUNTY HEALTH DEPARTMENT
f Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME
PROPOSED FACILITY
SUBDIVISION
Water Supply:
Evaluation By:
On -Site Well Community_
Auger Boring �� Pit
DATE EVALUATED
PROPERTY SIZE
ROAD NAME 14")�tpol S
Public �~
Cut
FACTORS
1 2 3 4 5 6 7
Landscape position
L
Slope %
HORIZON I DEPTH
Q
Texture groupGly
G
Consistence
Structure
1L
MineralogyJ
HORIZON II DEPTH
2
Texture group
Consistence
Structure
V_
Mineralogy
HORIZON III DEPTH
80- N X
Texture group
ex i�
Consistence
Structure
1�
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: Ps EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
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
�nwtcrem>�lvr>�
ois
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
DCHD (O1-90)
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Parcel #: 060000003507
Davie County, NC - Basic Estate Search
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View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
Parcel #: 060000003507 Account #: 39459500
Property Values
Owner Information
55,57
Tax Codes
17,6601
Land:
ACOBS BILLY D& WEST EARLEEN G
Market:
ADVLTAX - COUNTY T
ssessed•
12255
010 US HIGHWAY 601
Unqualified
FIREADVLTAX - FIRE TAX
9,000
t 00133 0423
ALISBURY NC 28144
Qualifled
Vacant
9,000
Property Information
Township
Land (Units/Type): 5.470 AC
JERUSALEM
ddress: 4123 S US HWY 601
Deed Information
Local Zoning
Date: 09/1986 Book: 00133 Page: 0324
Plat Book: Pa e:
Legal Description
PIN
5.57 AC HWY 601 LOT 6A
5754332325
Property Values
Building:
55,57
BXF:
17,6601
Land:
4932
Market:
12255
ssessed•
12255
Deferred:
Unqualified
Sales Information
No. Book Page
Month Year Instrument
Qual/UnQual
Improved
Price
. 00122 0701
04 1984 WD
Unqualified
Vacant
6,000
! 00133 0324
09 1986 WD
Unqualified
Vacant
9,000
t 00133 0423
09 1986 WD
Qualifled
Vacant
9,000
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=1462494 8/2/2016