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262 Deacon Way Lot 10 1 Davie County,NC �r 4 Tax Parcel Report Monday,December 19, 2016 i r I I i 256 262 'r 24G 2G5 r' 226 395 - cO,y . 1 259 ✓✓{}- 5 .. y t ' 5 ' r' i r WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number: K503OA0010 Township: Mocksville NCPIN Number: 5747562654 Municipality: Account Number: 56389620 Census Tract: 37059-805 Listed Owner 1: PETTICORD CALVIN BLAINE Voting Precinct: SOUTH MOCKSVILLE Mailing Address 1: 262 DEACONS WAY Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A State: NC Zoning Overlay: Zip Code: 27028-5182 Voluntary Ag.District: No Legal Description: LOT 10 DEACONS RIDGE Fire Response District: JERUSALEM Assessed Acreage: 2.70 Elementary School Zone: CORNATZER Deed Date: 6/1999 Middle School Zone: WILLIAM ELLIS Deed Book/Page: 003070120 Soil Types: WeB,MsC,CeB2,MsD Plat Book: 0006 Flood Zone: Plat Page: 061 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding&Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: [Oil All data Is provided as Is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless theCounty of Davie,North Carolina,its agents,consultants,contractors or employeesfromanyandagdaimsorcausesofactiondueto NC or arising out of the use or Inability to use the GIS data provided by this webslte. `+'" � �"`v*'' ... ✓- f 1,�„r,e•jC"ti[�-.w.��d u„t.,s c:,-.. -'.r.at;�-. -y,iev•+..-..,.,_. -, w _ .. XIA sr HEALTH DEPRTMEN DIMPROVEMEN�T�AND OPERAT ONA ERMITST PROPERTY INFORMATION *� 33 PerdlIt ee -�- Iyarlll: ;� og4oq �`'UB�' ��f�a a � Subdivision Name: Directions to property: A LOY LGJ S 'T L” Section: Lot: t ENT IMPROVEM ,,'/ U-c ,r PERMIT Tax Office PIN:4U147 56 - ;Z(105 - ..(" ► 1'T L; � 11�r 4*" �'t c czrRoad Name: LAC-LA L 1Y Zip: L 7t..�h **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) r�� ***NOTICE***THUS PERMIT IS SUBJECT TO REVOCATION IF SITE L'� _I PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER ENVIRONMA I`AL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. ,RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS--,7—#OCCUPANTS GARBAGE DISPOSAL:Yes o 110) COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE 2 w&1�E WATER SUPPLY�v^>►Y DESIGN WASTEWATER FLOW(GPD)�10 NEW SITE 1--" REPAIR SITE ! SYSTEM SPECIFICATIONS: TANK SIZE t GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 2 LINEAR jico OTHER STa,6,YT,y REQUIRED SITE MOD TIONS/CONDITIONS: C)N Ctx,�T&O(L 4 OVEMENT PERM L UT d0 k **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)634-8760. OPERATION PERMIT P r 13 C+ 6 V STALLED BY: a'Jet �10 a AUTHORIZATION NO. OPERATION PERMIT BY: ��/�/"I.� DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 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) 2,V , 4I APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE - J Davie County Health Department O Environmental Health-Section V P.O.Box 848 'L•�� Mock��sville�Ott 5 18 (336)751-8760 �';, ��r :IEMALH ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES D �lE 6 t ALTH ALL THE REQUIRED INFORMATION IS PR 1. Name to be Billed Contact Person 9- Uf Mailing Address iL3e',3 / Z41 - Home Phone qV:&99 �✓��"'` Z- City/State/Zip �"`�C �J I[ / GJ Business Phone - 2. Name on Permit/ATC if Different than Above Mailing Address City/Zip 3. Application For: L] Site Evaluation � Improvement Permit&ATC ❑ Both 4. System to Serve: House ❑ Mobile Home ❑ Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms Z E Dishwasher ❑ Garbage Disposal Br"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: `FF3" County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to server ❑ Yes Z]-�No If yes,what type? EITHER PROPERTY INFORMATION REQUIRED: ***IMPORTANT***A P%6SM THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: S-e-t- f- `GP 1 WRITE DIRECTIONS(from �j� LI � Mocksville)TO PROPERTY: Tax Office PIN: # 524-7 - �_ - �(O�T Property Address: Road Name ��rrc.Th ��`�1 1 l Y L nl- 11 T city/zip Yr—t-t. Z-7-1c. 1 If in Subdivision provide information,as follows: 1 1 Name: 1 1 1 Section Lot #: I U 1 1 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 to conduct all testing procedures as necessary to determine thesitesuitability. DATE '¢ O SIGNATURE Revised DCHD(06-96) YOU MAY USE THE $ACK Of THIS FORM FOR DRAWING YOUR SITE PLAN. d at 11:15 A.M. on November 19,1993 recorded In Plat Book 6 Page t-k-� 2 Page= MAL e;60;WNM PLATAFPMMAL tJAY f cr-. - ._ am er�rfwrwlr�re��r'�Ye+Me+rrMWeYe wr�ri 1�Yw� p'r/w l :,. • _ .s _. i rre�eb Ynle Ceew--mmeer.wew rr �+.e�~~ a�Yweeer1r r��� Dir ibrlT\ehrOwrar.�prT wrl��r� a's - �rwwt.rrrtirowerWew�.e...rr �enJea_,nal 1er�a erter�rrrrrrr�yeerr ev fer�rt.rr..y we__ _ T 7f6A � T.ow+sra."rr r.�rreewowea r••rrtR�----------- w.irtraer.r _S6Y-.C..�u�� .r...�r+rr�..."�..rgtr "�v�t*m[onE arses awees- r..e.t..r�rrr.esrer�Te.ea.�rrrrr rr�e�r wr r w�etq �"Cr�� Ttrtr___a�r [�-�rewe��ey�ee�r610irrrL we�^'er•I wl - yI___ TE LERITCJITE YA[6EDU ellg_ _ I�_J� �_ ererea Ire Tr_.e r_ Aw"aaaww err[ocuwr o.�c�aanMrr eDwroaenw- �� 4�+wr�.�r W—Tn hi Tm[ "mss . rt awae[ Ksnwuwlw. reac. aoerr Ds owc canrr er - OERIrY./SSE .rr _ WLLW1 MMM- ET AL OM 75 K.343 ss 3 Q OS lT[ 1.94.T?TOTAL*7439 • •00.23 S 330.00 26w75 a �� O AREA=2586 ACRES O ve' y in g Q rye. F1O O 0. y J h h AREA=3 3T7 ACRES � Jd^T8 i Q� ��# iC>���/ ° T T� , c04, .6A ► Y " ?040 zp' of -w, a b AREA-3.222 ACRES \ (t '{�r a f�� .�•�e.a .?> 4��+fgyy i��b`•' \\ ;c .t 0 O •tit h I Q �3J I • 'r'~ ?may ��r`''a.°ie 0 Y1 •ane y[ yJ v. \ / �±►, ' APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT &ATC Davie County Health Department 2� t2 O i1 n i2 a� 8 Environmental Health Section L5 I5 1J 1:5 x 4 P.O. Bo 8 8 Mocksville,NC 27028 JUL 1 1 1996 �✓' �ByJ (704) 634-8760 ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESS THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed.'�J Bat lev Contact Person r z4 BQz'lev Mailing Address y Z'ittrLl4/4W • HomePhone(70`�)a"- 9/a8 City/State/Zip�&0� 5 J� �NJ • �aOff Business Phone^(90L/) 2. Name on Permit/ATC if Different than Above Mailing Address City/State/Zip 3. Application For: [ Site Evaluation ['Improvement Permit&ATC [ ]Both 4. System to Serve: [House [ ]Mobile Home [ ]Business [ ]Industry [ ] Other 5. If Residence: #Peo le � #Bedrooms Ll_ #Bathrooms [vJ'Dishwasher[ ]Garbage Disposal [4/Washing Machine [ 1 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: [County/City [ ]Well [ ]Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve?[ ]Yes "No If yes,what type? PROPERTY INFORMATION REQUIRED:***IMPORTANT***A FLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS(from Mocksville)TO PROPERTY- Tax Office PIN: # L O c sa tem O Tu r7'p 7 Property Address: Road Name } �� Q c c5h 15 IC Cd a e csv� L City/Zip ; If in Subdivision provide information,as follows: Name: �eQ Cbn _S Section: Lot#: ID 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. 1, 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 to conduct all testing procedures as necessary to determine the site suitability. DATES //� SIGNATURE Revised DCHD(06-96) d at ll:IS A.4. on November 19,1993 recorded in Plat Book 6 Page - - l §CrVMMPLA(APPWVAL t- ra .-u,_— —ft , . Z P ge8 NMwLTraraalwaeYP•/•r/rw�.m.rraae.,.�.w/.srarw '•i�ra/a I�Yr+Yryy/r./eaoYr Yw t Ab�'r oar�rr/Iw)a6f aay.�oYn �YTlaris _.___�_ .••.•'.`�•.�•-`�- - . ..�MI�fIrFd�uw�r�wwcoarP �YPab wra �.�t/w..ww/w r___rte—:)M —.r�sc.---. r Y°Y w�►MG.r�rl w[__ ___ F�e,�� www...r..ru�rru.��rwai+w/a...,.rw+a �_aa._.����r{{��e�.i n.wr.r+..•�°r.r.°4 Yrr.�+/ wo wc,oY — ' rrwYl.2G�L___ Y'./dwYw -3AltY_11GtL.__,1.�ry YM�+/bb/a///s r1�/ YC WtI/l TTF6 TE 0FFIC �� ),Oti♦�ti w/r Orr Y,YarP/rwlbafid.r a/^// rrr��/xr,Ys11�°fYYYrarrt/Y,.rY brt aYe•Y�./a,Yraw rti 4+Ly u.Mr Ti CEfRfIUTE PA55E0U iR11LT(i�A P/�_:areYa�r�P�blrYYr,Yral Gi Aib�rrl m7n�rtleY�s"vl ar _ — •1a�t ---_—__,n—_.__. Oa)F_.._ .G1=.1�.-.'1.�._..._._ 'y,ba+s/✓f_.___._.__.____ ____ (3w9 —__sbwnsE.w rm[ wrt..r __—.—__—_— OF —_ oAr(oou/rt r1a.�...ae��,./_.___-_.__...__—_._. rs +'°"� P,•..arm/.� �MtliI1QaM. Oit CO{Mf7 OaEROI RAlef4 Ir)1)IN G/IOIA. Igfi1M LW1Ni. 01Mt tG1(lY ...'......._........ WILUAM HALL. ET AL DQ 75 K.343 ` .... ser or 3a-c ies4.n rout 474.7 wozl aso.o0 x,73 3U� 3 AREA=2.586 ACRES O Q h S AREA=3.377 ACRES 311) 1 pd° o f COO 0& "040 ao `r i \ AREA=3.222 ACRES / 2� $ '�'8 ��oe��'�°'o•.• "" , \� N , � O '3.� vie 'r>000 0..e.°°'• \` •� E +�;�r • \� \ \ B ��X69 CP aye Q�[uy O � \°ea�`� ^ 2�zP• J Q. I 0 P o- '\ ,�• it • DAVIE COUNTY HEALTH DEPARTMENT 0 Environmental Health Section Soil/Site Evaluation NAME' Cf' I_Ao DATE EVALUATED ADDRESS �/� PROPERTY SIZE PROPOSED FACIILTY Com' LOCATION OF SITE Water Supply: On-Site Well Community Public <� Evaluation By: Auger Boring Pit r/ Cut FACTORS 1 2 3 4 Landscape position .Z 2- Slope % - HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH Texture groupG Consistence i 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: EVALUATED BY: LONG-TERM ACCEPTA E RATE: OTHER(S) PRESENT: REMARKS: LE END 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 DCHD(01-901 ........................... ................... .................. ■■■■■■■.■■■.■■■■■■.■.■..■■■.■■■ ■■...■■■■■..■■■.■■■■■.■■■tit■■■■ ■■.■■■■■■■■■....■■■■■■■■■■....■■ SEE ■a■..ri■■ .■■.■■.■■.■.■■■.■■■■.■ ■■.■■■■■■■■■■.■.....■■H.■■■■■■■■■...■■■..■■.■■■■■■■■ ■■■■■■■■■■1■ Emmu mom iiiiiiilii■iiiiiiiiiii■iiiiiiiiii■.iii■=�. ii■i�i ■■■uC.. ■uM■. ■ ......■.■..■...■■n■■.......■■..■.■..■ . ■ il ■ ■■■■■.. 1� ..............■.................... ......■.■.. ...■■■■...■.■■■. ■■..■..........■■....■■..■.■■.■.■■ria.. ..■ n.■ ■ .. ■■ ■.■■...■ ..................................H _: �: :: �? :SMC:: ::::::::. ::::::: MEN : :::�::::::::::::::::::�...�SlI ■��■.■..■.ME.�■■ ■..■■■■■.■..■■■■■■■■..■..■■■..■...■..H.OELr■�■ .■1�MUM�M.MOMM■■MM ........................■.■■..■!..■■H■■.■��■■■■WON MEMO ■.■n=■■■ ................................ .......�.................■. ■.■■ ■■■■u■■■■■■.■■■.■■■■■■■■■��:ii�w�!\�■■■ ■■■..n■■.■■■■■■■.■■■■■■ ■■.■..■A■■..■..■■■..I..■ ■..■■■.■■■H.H ►H■ MEMEMEMOMEMEMEMEM ■■■■ ■...■■H■..■■■■..■11■■■■■■■ ■.■...■■■.■.■......■■.■.■.H■.■■ DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation / NAME ' � DATE EVALUATED, ADDRESS PROPERTY SIZE PROPOSED FACIILTY ��« LOCATION OF SITE —APWc,2&< t� Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 r 2 3 4 Landscape position Slo e % L HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH " o "r Texture groupG� Consistence 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: I� EVALUATED 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 :lay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Vc.-y 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 3C-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(01-901 ■■■■■■■e■■■■■■■■e■■■■■■■■■■■■■■■■■■■■■■■ ■NN■M■■I■■MMM■■■ ■■■■■■■ ■■■■■■■■MMMe■MMM■MM■M■N■MMM■■■■■�■■■/■■■■■■■■■■/■■■■■■■■■�/■■■■■ ■■■■M■■■■■■■■■/■■/■■■/■■■/■■/■■■■■M■MMNN■ Ne■eeeNMeeNNMNM■MM■MO■■■ ■■■■■■■■M■■■ee■M■■■MM■■■■■■NMM■■■e■■■M■M/ee■N■O■Ne■■Ne■e■■■MeMESON ■■MMMM■eee■■Neeeeeee■■■eee■■■eMMee■■■■■Ne■N■e■ee■e■■■e■■ee■■■eee■■ .....■..........................■..........�........ 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NM■MMN■■ ■■■■M■11■■■M■M■■11N■MM■■■■MM■■■MMM■■N■■M■■M■ ..........=■■■■N■■... ................IN.......................... ■■eeeN■■eeeeNeeNMee■■■■■■■■■■■■M■■■ee�IN■■■Mee■■■eeH■Meeh■NMee■■■ ■■■/Nee■NMMMMM■■■■■■■■■■■NM ■N■■MONMM�IMM■■NNMMMeeeMMNM■■■eMN■■MOM■ ■■■■_■■■■■■■■■■■e■■■■■■■■■■ ■■N■■NN■■NIO�O■■■■■■■■■■■■■■■■■■■O■■■�■ =NM■NeeNNMMM■■■■■MMMMM■MM■■■IINNM�NMM.NMMMNe■NM■N■■M■■■■■NMN/■■■■■ f ' Davie County NealtFr 7yen artment and dome Nealtficy 210 HOSPITAL STREET P.O. BOX 665 MOCKSVILLE,N.C. 27028 PHONE:(704)634-5985 July 22, 1996 Cloyd Bailey 432 Riverdale Rd. Mocksville, NC 27028 Re: Site Evaluation Deacons Ridge Lot 10 Tax PIN: #5747-56-2654 Dear Mr. Angell: As requested, a representative from this office visited the aforementioned site on July 18, 1996. Based upon the information provided on the application for site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on-site sewage disposal system. If you have any questions, please feel free to contact this office. Sincerely, p Robert B. Hall, Jr. , R.S. Environmental Health Section I RBH/wd Enclosure(s) 1 C1C%Swlcecodcl-k �� (3-3'181 f i HEALTH DEPARTMENT RELEASE(" For office use only *CDP File Number 233857-1 Davie County Health Department 5747562654 ` 210 Hospital Street County ID Number: P.O.Box 848HDR/WWC Evaluated For: Mocksville NC 27028 Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID 0 a / 0 8 / a 0 a a UNTIL: Applicant: Blaine Petticord Property Owner: Blaine Petticord Address: 262 Deacon Way Address: 262 Deacon Way City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: �(�33909-3600 Phone#: �(�33909-3600 Property Location&Site Information Address 262 Deacons Way Subdivision: Deacons Ridge Phase: Lot: 10 Road# Mocksville NC 27028 SINGLE FAMILY Township: 'Structure: Directions .#of Bedrooms: 3 #of People: 2 Hwy 601 south,left on Deadmon Rd.Left on Turrentine Rd left on Deacon Way *Water Supply: PUBLIC Type of Business: Basement: F—]Yes0 No Total sq.Footage: No.Of Employees: *Proposed Improvement: Shop Characters *Release Conditions Remaining Stay 5'minimum away from all parts of the septic system. 693 This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps.Signature Required? O Yes ®NO Applicant/Legal Reps.Signature* *Date: / *Issued By: 2325-Mitchell,Brittany � ,, �/ *Date of Issue: 0 a / 0 8 / 2 0 1 7 Authorized State Agent: qM^ 31c?j / Ic�lL�nlJ�(. **Site Plan/Drawing attached.** ®Hand Drawing 0 Import Drawing HEALTH DEPARTMENT RELEASE 233857 - 1 r Davie County Health Department CDP File Number: 210 Hospital Street 5747562654 P.O.Box 848 County File Number: Mocksville NC 27028 Date: 0_a./ 0.8./ ..0.1.7 4 . O Inch Scale: O Block = ft. Drawing Type: Health Department Release O N/A {..... .. . . . ........I ....... .. .... I I ......... ..... ....... . ;.. . ..L ....... ...... x _ ...... I ........ 1 .......I .... ....... ...... .... ti ...... ............................ .... . ........ ... .... ....... ...... " ........ � ... ........ _ ..... ....... . ....... ......... ! _.... ! i . I.. I� I .. . . . ........ ... us ....... .........I .... .. I . .. .I ..... ... ...... .... 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L ............. ............. ........., Page 2&2 2 33$s� Davie County Health Departinent 4�; I EnN onmental Health Section " �. P.O. Box 848 RECEIVED f REG Street ' ` 0 ��,� 210 Hospital Q Courier# : 09-'10-0G j Z� I Mocksville, NC 27028 ��1 r. Phone:(336)-753-6730 Par(336)-753-1630 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: !/�"/N� 4A. el / Phone Number (Home) Mailing Address:Apz' W � 3��0 �09�'3� (Work) ���s�.1 <� �t/6�Zdur DetailedDirections To Site: rP 0 L �J j L dlyu� Property Address:_ �� Please Fill In The Following Information About The EXISTIYG Facility: Name System Installed Under: Rx y k(4 bb �%fK : Type Of Facility: /OOU Se o2.—7o f;C,Q&s Date System Installed(Month/Date/Year): Number Of Bedrooms: Number Of People:. Is The Facility Currently Vacant? Yes N�i If Yes,For How Long? Any Known Problems? Yes No I Yes,Explain: filPlease Fill In The Foll living Information About The NEWFacility. `Q� Lt�OO - Type Of Facility: Number Of Bedrooms:--(S�umber of People. Pool Size: Garage Size:� ,X40 Other:. Requested By:�P ��� r Date Requested: 9>/—,Zq Q (Signature) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will function properly for any given period of time. Payment: Cash Check Money Order P Amount:$ Date: Paid By: Received By: Q Account#: Invoice#: bde(/ f t c � q 3 Aop is hldzkd e�p_