1601 Hwy 64E DAVIE COUNTY HEALTH DEPARTMENT ��
j Environmental Health Section
'1` . �'�' _ P.O.Boz 848/Z10 Hospital Street
` Mocksville,NC 27028
(336)751-87C0
.
IMPROVEMENT/OPERATION PERMIT .
Account #: 990002311 Tax PIN/EH#: 5758-31-1925
, Billed To: Jim Lipscomb Subdivision Info: ��Q� lj(S�l� �ylfG
Reference Name: Location/Address: Highway 64 East-27028
Proposed Facility: Residence Property Size: see map
ATC Number: 3179
**NOTE** This ImprovemendOperation Permit DOES NOT authorize the construction 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). THIS
PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR
WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type tJv�� #People � #Bedrooms 3 #Baths 2 ��
Dishwasher: � Garbage Disposal: �" Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: �
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size •'7� �""��ype Water Supply WEI� Design Wastewater Flow(GPD) c�LJ Site: New�Repair❑
System Specifications: Tank Size ��GAL. Pump Tank GAL. Trench Width��� Rock Depth� Linear Ft. ��
ocher: �' �5T21�7�%l�^J ���%\ . �nI�TALt- L-.l,✓LS G'a•C.M�✓.
Required Site Modifications/Conditions: i'/�/,�qLL c� C�+✓f�i �N�' «f��% �"'�=�7 �d�0� ��
L/n1�
Ih7PROVEMENT/OPERAT(ON PERMIT LAYOUT- APPROVED EFFLUENT FiLTER RISER(S) IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis
system bet�veen 8:30 a.m.to 9:30 a.m.or 1:OO,p. .to 1:30 p.m.on the day of installa 'on. Telephone#is(33G)751-8760.****
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Environmen al Health Specialist's Signature: D t . Q'
` DCHD OS/99(Revised) �Q(Zp)(. � ,
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/ . DAVIE COUNTY HEALTH DEPARTMENT
, ' � • . r Environmental Health Section d 7.� � � U Z_.-----
' � � P.O.Boz 848/Z10 Hospital Street �
Mocksville,NC 27028
'' (336)751-87G0
IMPROVEMENT/OPERATION PERMIT
Account #: 990002311 Tax PIN/EH#: 5758-31-1925
� Billed To: Jim Lipscomb Subdivision Info:
Reference Name: Location/Address: Highway 64 East-27028
' Proposed Faciliry: Residence Property Size: see map
ATC Number: 3179 .
**NOTE** This Improvement/Operation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater
system. An AiTTHORIZATION 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). THIS
PERNIIT IS SUBJECT TO REVOCATION IF SITE PLANS OR T��INTENDED USE CHANGE. YOUR ,
� WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM.
Residential Specification: Building Type� JSE #People � #Bedrooms 3 #Baths 2�S
Dishwasher: � Garbage Disposal: u Washing Machine: � Basement w/Plumbing: � BasementlNo Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size �`'�5�� Type Water Supply�LL Design Wastewater Flow(GPD) 3 (� Site: New�Repair❑
2 �r .� i/_�
System Specifications: Tank Size�Q�^�'rAL. Pump Tank GAL. Trench Width J�e Rock Depth �2 Linear Ft. �ft•CJ
arn�: S 1�1�'T21Q�n�a �e�c�s, �n�S�"Qur ���1�s �o.C. M,iN.
Required Site Modifications/Conditions: �^tSTOLI O�I Gp,JYq?f�� �`� I�,6�F F�, �[�� �Of D(-F PeoQ. LIJ�
INIPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTE RISER(S)IF 6"BELOW
FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health D ent for final inspection ofthis
system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day installa ' . el one#is(33G)751-8760.****
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Environmenta Health Specialist's Signature: 4' Date:
' DCHD OS/99( evised) T� ��� �'-`E 'd`��''
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' � " DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section �
P.O.Boa 848/210 Hospital Street
Mceksville,NC 27028
' (336)751-8760 ,
- Account #: 990002311 Tax PIN/EH#: 5758-31-1925
Bilied To: Jim Lipscomb Subdivision Info:
Reference Name: Location/Address: Highway 64 East-27028
Proposed Faciliry: Residence Property Size: see map
ATC Number: 3179
AUTHORIZATION FOR WASTEWATEft SYSTEM CONSTRUCTION -
**NOTE** This Authorization far Wastewater System Construction MUST BE ISSLJED�the Davie County Environmental
Health Section prior to issuance of any building permit(s). This Form/Authorization Number should be presented to
the Davie County Building Inspections Office when applying for building permit(s)(in compliance with Article 11 of
G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems). THIS
AUTHORIZATION FOR WASTEW S I OR A PERIOD OF FI ARS.
Environmental Health Specialist's Signatur : ate: � DG—
CERTIFICATE OF COMPLETION
**NOTE** The issuance of this Certificate of Completion shall indicate the system described on Improvement/Operation Permit
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 tee that the system will function satisfactorily for any
given period of time. �
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Septic System Installed By:
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Environmental Health SpecialisYs Signatur . Date: � �� �3
DC�ID OS/99(Revised)
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CATION FOR S17E EVALUATION/IMPROVEMENT PERMIT&A . �' � `�..
Davie County Health Department 1 � c; r,�
� Environmenta/Hea/th Section �'� ���-� �
� � � P.O. Box 848/210 Hospital Street ""-
Mocksville, NC 27028 �G�� r`' " ,. 7 `
D �M9. , ,�
t�� '� Q J� (336)751-8760 . .
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*IMPORT ���'HIS LICATION CANNOT BE PROCESSED UNLESS ALL UI J JYfh1Ty
I �{'l VI�DED. Refer to the INFORI�TION BULLETIN for instructi ,
1. N e Billed�((�(� �,�'��(`(\� Contact Person�/ vl'� �r �f�/�,'1(a
Mailing Address ��3 V �V � 5 8 Home Phone _Q �O � a 3�
, City/State/ZIP ���'V1 .1r .l�• Z!DG O Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Pexmit/ATC �Both
4. System to service: �House � Mobile Home � Business ❑ Industry ❑ Other
5. If Residence: # People .3 # Bedrooms � � Bathrooms o�-�7...
`L✓Dishwasher E3�Garbage Disposal LN�ashing Machine �Basement/Plumbing ❑ Basement/No Plimbing
6. If Business/Industry/Other: Specify type # People i Sinks
li Commodes # Showers # Urinals # Water Coolers
IF EOODSERVICE: # Seats Estimated Water Usage (gaiions per aay)
7. Typa of water supply: ❑ County/City . @�Well ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? ,, �Yes �No
If yes,what type?
***IMPORTANT***CLIENTS MUST COMPLETETHE REQUIRED PRQPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BESUBMI7TED by the client with THIS APPLICATION.
� Property Dimensions: �"e'� ��"` `� WRITE DIRECTIONS�(from Mocksville)to PROPERTY:
�
Tux Oftice PIN: # ���,5 g � 3 / — � ( a J� �l!_f���E V��Q VL/
Property Address: Road Name G �t� J b u`h �N-p'�,�5 �pG�d1 Qu�r�
�►ty�Z�p _Ga����� R�• �o N L��f
If in a Subdivision provide information,as follows:
Name:
Section: Block: Lot: � .Date Property Flagged: ���o � o �
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hercafter 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,,undersland that I am responsible for al!cl:arges incurredJrom
, tliis application. I,hercby,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.
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DATE (.� ' I(� � D� SIGNATURE GD
. �
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Include all of the following: Existing and proposed
property lines and dimeasions, structures, setbacks, and septic locations).
Site Revisit Charge
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Date(s): • ,_�1
�� Client Notification Date:_��_ ,
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� � ` DAVIE COUNTY HEALTH DEPARTMENT
' �� '~ + Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION .
Account #: 990002311 Tax PIN/EH#: 5758-31-1925
Billed To: Jim Lipscomb Subdivision Info:
Reference Name: Location/Address: Highway 64 East-2702
Proposed Facility: Residence Property Size: see map Date Evaluated: � q �Z
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit - Cut
FACTORS 1� 2 3 4 5 6 7
Landsca e osition �— L
Slo % �D
HORIZON I DEPTH -r' ^ ��- � '� .-
Texture rou bt-� I Li
Consistence ,, � ' ` �"f1��- ;
Structure r � �� L
Mineralo �� ,' ;
HORIZON II DEPTH .-< ^ -
Texture rou � �1"
Consistence � S
Structure -
Mineralo � � � ' `
HORIZON III DEP'TH � �
Texture rou S:
Consistence ` � `
Structure �
Mineralo ; I ' ,
HORIZON IV DEPTH
Texture rou '
Consistence
Structure � �
Mineralo
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
`CLASSIFICATION '
LONG-TERM ACCEPTANCE RATE .� �. .�
SITE CLASSIFICATION: � lC�,` � EVALUATION BY: ��"`r
LONG-TERM ACCEPTANCE RATE: �' � ' OTHER(S)PRESENT:
I
REMARKS:
LEGEND
Landscape Position
R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope '
CC-Concave slope CV-Convex slope T-Tenace 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-Subangulaz blocky PL-Platy PR-Prismatic
Mineralo�v
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)
1 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-gaUday/ft2
� DC�ID OS/99(Revised) �
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Parcel#: J60000001003 Page 1 of 1
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Davie County, NC - Basic Estate Search �ov�,�'
Davie County Web Site
,8asic Search Real Estate Search Tax Bill Search Sales Search �
View Prooertv Record for this Parcel Vfew Ma�for this Parcel Yiew Tax Bill Information
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Parcel#:J60000001003 Account#:45788000
Owner Information Tax Codes
PSCOMB CHAD A&LiPSCOMB JAMES C]R&NANCY ADVLTAX-COUNTY T
1601 US HIGHWAY 64 EAST READVLTAX-FIRE TAX
OCKSVILLE NC 27028
Pro e Information �Townshi
rld (Units/Type): 4.410 AC MOCKSVILLE
ddress: 1601 E US HWY 64
Deed Information Local 2onin
ate: 07/2009 Book: 00801 Page: 0171
Plat Book: Pa e:
Le al Descri tion PIN
.454 AC US HWY 64 LIFE ESTATE 5758204817
Pro e Values
Buildin : 288 72 .
BXF: 19 76
Land: 36 05
Market• 344 53
ssessed: 344 53
Deferred•
Sales Information
No. Book Page Month Year Instrument Qual/UnQual improved Price
1 00495 0408 07 2003 WD Unqualifled Improved 234,000
00796 0896 06 2009 QC Unqualified Improved 0
00801 0171 07 2009 WD Unqualified Improved 0
00422 0245 OS 2002 WD ualified Vacant 30 000
View Pronertv Record for this Parcel View Mau for this Parcel View Tax Bill Information
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All information on this site is prepared for the inventory of real property found wlthin 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 fnformation sources should be
consulted for verification of the information. All information contained herein was created for the Davie County's fnternal 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 inerchantability and fltness for a particular use.
If you have any questlons about the data displayed on this website p�ease contact the Davie County Tax Office at(336) 753-6120.
1.5.9
http://maps.daviecountync.gov/itsnet/View.aspx?prid=1458994 6/28/2016