3181 Hwy 64Ed
Davie County Health Department
40N►8 j� Environmental Health Section
P.O. Box 848
C�
A 210 Hospital Street
Q U 1A'� Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680
(Check One) Replacement Remodeling Reconnection
Name: /"0 f k Vo I Yet 4 -e 4 ✓ Phone Number 3 � � � � � - � S (Home)
Mailing Address: 91,0 VS 1a wo & t 1 9 (Work)
X)ya i,cz, 1A, 92Do2 Email Address:
Detailed Directions To Site:
Property Address: Al! 6 G's C u e-Sd (✓ Fire. -P..
Please Fill In The Following Information About Thee EXISTING Facility:
Name System Installed Under: %V/ )
T _/y "/ l//�' l� : /V . / % Of Facility:
Date System Installed (Month/Date/Year): �! Number Of Bedrooms: � 1, Number Of People: E-)
Is The Facility Currently Vacant? Yes No If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In Theollowing Information About The NEW Facility:
Type Of Facility: /l l'i d Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other: 7Jn// 120 041t
Requested By: �7 . Date Requested:
(Signature)
Comments:
For Environmental Health Office Use Only
Environmental Health Sveci
Date:
Z
*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 # Amount:$ Date:
Paid By: Received By:
Account #: Invoice #:
0
Appraisal Card
Page 1 of 1
FORK VOLUNTEER FIRE DEPARTMENT
Retum/Appeal Notes:
37 -120 -AD -019 .
3195 E US HWY 64
UNIQ ID 19834
5838000
NN: 26 - CHANGE OF OWNERSHIP
D372 -P14
ID NO: 5777283052
COUNTY TAX (100), FIRE TAX (100)
CARD NO. 1 of 1
eval Year: 2009 Tax Year: 2013
.79 AC HWY 64
0.820 AC
- SRC= Inspection
Appraised by 07 on 07119/2007 04001 FULTON
TW -04
C- EX -2 AT- LAST ACTION 20121109
CONSTRUCTION DETAIL MARKET VALUE
DEPRECIATION
CORRELATION OF VALUE
Foundation - 3
Eff. BASE
Standard
0.4600
ontinuous Footing4.00
u5 MOD Area QUA RATE RCNEYB AYB
CREDENCE TO MARKET
ub Floor System - 4
Plywood
9.00 77 104 12,5881 113 181.36121055911974196
% GOOD 1 54.0 DEPR. BUILDING VALUE - CARD
113,70
Exterior Walls - 21
TYPE: Club, Lodge, Hall -
Office Construction DEPR. 08/XF VALUE - CARD
ace Brick
25.00
MARKET LAND VALUE - CARD
18,24
oofing Structure - 03
STORIES: 1 - 1.0 Story,
ry ,
OTAL MARKET VALUE - CARD
131,94
able
7.0
Roofing Cover - 03
OTAL APPRAISED VALUE - CARD
131,94
Asphalt or Composition Shingle
2.0
NOTAL APPRAISED VALUE -PARCEL
131,94
Interior Wall Construction - 5
D wall/Sheetrock
22.0
Interior Floor Cover - 05
TOTAL PRESENT USE VALUE - PARCEL
Asphalt Tile
2.00
TOTAL VALUE DEFERRED - PARCEL
Heating Fuel - 02
TOTAL TAXABLE VALUE - PARCEL
131,94
II Wood or Coal
0.0 +-------39--------+
eating Type - 03
1
I
PRIOR
orced Air - Not Ducted
3.0 9
- 9
BUILDING VALUE
99,56
Ir Conditioning Type - 03
+ - - 1 4 - -+
1 U B M
+8-+
I
BXF VALUE
ND VALUE
0
15,58
entral
6.0 I
1
RESENT USE VALUE
tructural Frame - 04
I
I
DEFERRED VALUE
[son
4.0 I
2
I
2
OTAL VALUE
115 14
eiling & Insulation - 07
Not Suspended - Ceiling and Wall
q 0 8
8
-
nsulated
I
i
I
I
verage Rooms Per Floor - 6
I
I
veraeRooms Per Floor
0.0 +--.----------61-------------+
PERMIT
Plumbing Fixtures
CODE I DATE NOTE I NUMBER AMOUNT
.00
8.00
OTAL POINT VALUE
6.00 +-------39--------+
I
I
ROUT: WTRSHD:
BUILDING A03USTMENTS 9
9
SALES DATA
Uali 131 AVG
1.000 + - - 14--+
+8-+
FF.
ha a Desi n 4 FACTOR 4
1.040 1 6 A S
I
RECORD DATE I DEED INDICATE
Ize ' 131 Size
11.1300 1
I
1
I
AG
OOK PAGE M R TYPE / SALES PRICE
11)007110467
NOTAL ADJUSTMENT FACTOR
1.18 I
I
0883 2 01 WD E I
OTAL QUALITY INDEX
11 2
2
8 196 WD X I
8
8
I
I
I
I
I
I
+----25-----+-12-+----24----+
BUILDING AREA 2,059
4FOP 4
+ - 12-+
NOTES
SUBAREAUNIT
ORIG %
SIZE ANN DEP % OB/XF DEPR.
GS
OD UALI DESCRIPTION HUNIT PRICE COND BLDG#L
FACT Y EY RATE V CONDI
VALUE
TYPE AREA % RPL CS OTAL OB/XF VALUE
BAS 2,05 10 16752 -
FOP 4§031 113
BM 2 059 ON4190 -
FIREPLACE 1 - None
UBAREA
4,16 10,55
TOTALS
'
BUILDING DIMENSIONS BAS=W8N9W39S9W14S28E25FOP=S4E12N4W12$E36N28$ PTR=N15 UBM=N28W8N9W39S9W14S28E61$S15$.
ND INFORMATION
HE
R JUSTMENTS
LAND
TOTAL
ND BEST
USE
LOCAL
FRO N
DEPTH / LND
GONDrTHDENOTES;
ROA
UNIT
LAND UNT TOTAL
ADJUSTED LAND
LANNOTAL
CODE
ZONING
TAGS
DEPTH
SIZE MOD
FACTRF AC LC TO OT
TYPE
PRICE
UNITS TYP ADJST
UNIT PRICE VALUE
NOTES
3
7700
213
0
2.6100 4
1.2000 +10+10 +00 +00 +00
PW
7 100.0
0.82 AC 3.132
22237.2 1823AL
MARKET LAND DATA
0.82 1824
PRESENT USE DATA
http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=J7120A0019 12/11/2012
Parcel #: J712OA0018
Davie County, NC - Basic Estate Search
Basic Search Real Estate Search Tax Bill Search Sales Search Q
View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information
Parcel#:17120A0018 Account #:25838000
Owner Information
uildin
Tax Codes
BXF•
ORK VOLUNTEER FIRE DEPARTMENT
Land•
hDVLTAX - COUNTY T514
Market:
US HWY 64 EAST
ssessed:
EADVLTAX - FIRE TAX
Deferred:
DVANCE NC 27006
Property Information
Township
Land (Units/Type): 0.000
FULTON
ddress: 3181 E US HWY 64
Deed Information
Local tonin
Date: 03/1992 Book: 00162 Page: 0841
Plat Book: Page:
Legal Description
PIN
1.63 AC HWY 64
25838000
Property Values
uildin
254,77
BXF•
01
Land•
10,93
Market:
265 70
ssessed:
265,70
Deferred:
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
_00162 0841 -03 - 1992 -WD__— _--_Unqualified_.- _ Vacant 0
View Prooerty Record for this Parcel View Mao for this Parcel View Tax Bill Information
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O-' wrc1`
000110111-
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=1457710 6/21/2016
DAVIE COUNTY HEALTH DEPARTMENT
•- - (Septic Tank) Improvements Permit and Certificate of Completion
j-: (Ground Absorption Sewa a Di s osal System-, G.S. Chapter 130 -Article 13C)
MMR OR CONTRACTOR ` f DATE PERMIT
O
LOCATION �}. • 4.a� .� ' � ;"- •, 'r 31� 1 u� �iWy (� c l� . 998
S.R. NO.
SUBDIVISION NAME LOT NO. SECTION OR BLOCK NO.
HOUSE ❑ MOBILE HOME O BUSINESS Q
NO. BEDROOMS lz� NO. BATHROOMS
GARBAGE DISPOSAL UNIT YES ❑ NO y
AUTO. DISHWASHER YES ❑ NO
AUTO. WASH. MACHINE YES ❑ NO \_
SITE SUITABLE YES [3'y NO
SIZE OF TANK 90D gal.
NITRIFICATION FIELD sq. ft.
DEPTH OF STONE IN LINES:
WATER SUPPLY: Individual,., ❑ Public ?
r.
IMPROVEMENTS PERMIT BY
House Trailer
800
Gal. 400
Sq.
Ft.
Two Bedroom House
800
Gala 600
Sq.
Ft.
Three Bedroom House
900
Gal. 900
Sq.
Ft.
Four Bedroom House
1000
Gal. 1200
Sq.
Ft.
INSTALLED BY
CERTIFICATE OF COMPLETION BY Date 7—a,1-76
(8/16/73) *Construction must c mply with all other applicable State and local regulations
LOT AREA
k t �
at ,
per DAVIE COUNTY HEALTH DEPARTMENT~ 41,-e4 "tl
-Name: ,. Z" Z r' Environmental Health Section PROPERTY INFORMATION
�g�--P.O. Box 848`
Directions to property:' f I. .iV :11A A Mocksville, NC 27028 Subdivision Name:
1 Phone #: 336-751-8760
r ,� ;.. Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION -
AUTHORIZATION NO. i 1 A } Road Name: - 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 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Diskal Systems)
/��% r / ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
x I f �/� IS VALID FOR A PERIOD OF FIVE YEARS.
EI VIRONMEN AL HE(ALTIi MECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE ! , n F �f PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL1WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY C' (Z_ DESIGN WASTEWATERFLOW (GPD) rL NEW SITE REPAIR SITE f
SYSTEM SPECIFICATIONS: TANK SIZE,�rLGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
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 (336)751-8760.
AUTHORIZATION 1462&� OPERATION PERMIT BY:DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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 13E TAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. `
DCHD 02M (Revise
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION 0
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) do
•NAME _4 lelPHONE NUMBER
ADDRESS -c7 Z ., (o / SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING
DATE REQUESTED INFORMATION TAKEN BY .1_7C-4 h/ ---
This Is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193 // �_ 1,-)
— r ( r /