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'*�► . DAVIE COUNTY HEALTH DEPARTMENT �
�. � � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
�NOTE:"Issued in Compliance with,G.S. of North Carolina Chapter 130 Article 13c
--.. � Sewage Treatment and Disposal Rules (10 NCAC;10A .1934-.1968) Pe�t111t NUmber
�►vame.<-��....���a,:���ri�i'% i�������'di'��r.- /�i Date -1��� J\��6� N 0 ��-'�j i a�_
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�Location f�J�.^!� ��`�%'s/�'..�.f .�;�;� f%''Yic'� _���'�%/ ,r`i� �� _
,��f �
� — .
Subdivision Name Lot No.� Sec. or Block Na "
Lot Size House /� — Mobile Home _ Business Speculation
No. Bedrooms � No. Baths� No. in Family�—
. Garbage Disposal YES p NO � Specifications for System:
Auto Dish Washer YES � NO �p � �,���� �/'js��
Auto Wash Machine YES NO �p � � �. �. �
TYPe Water Supply /.,�/��� -- j ���-'J��/��� .>�-J �'�4�
*This permit Void if sewage system des ribed below is not installed within 36 months from date of issue.
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Improvements permit by -���"
*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 day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by--�d� O
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Certificate of Completion L�' Date �, �
'The signing of this certificate shall indicate that the system described above has been installed in compliance with � `��, �:
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function �.,
satisfactoril�c.for any given period of time. �'°��
DAVIE COUNTY HEALTH DEPARTMENT
` ��`'�"`�M � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
��,�rx�8',���,lle Permit Number
Name � i:}'. tr, .. ;,s �, �.+;;,. j` ,,.. - _ ate ' ` ! �� '; `a�i�` E�
`-
;Location ��� f; �.r^'1�"7_ �'lt..ri ' � !.•',�. -_ J��),�'.e.: ,' , . 1�� fi��r,:F.r f�iFc i:> _
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home — Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES p NO p"� Specifications for System: �'�'f��% �l=-r��i� �`i"` %
Auto Dish Washer YES p NO p j �� ,_ '-' ,
Auto Wash Machine YES 0 NO �p `�y�'�� ' f ;i :'� '���!'���-':
Type Water Supply r' ��' `_s_. --- `` �: ,,r: u�� �. ��.,._�:<. . .._
Y
l�
"This permit Void if sewage system•described below is not installed within 36 months from date of issue.
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Im rovements ermit b i �'r`' ''
p P Y - �'.
_— � -- ---
"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 day of completion. Telephone Number: 704-634-5985.
Final lnstallation Diagram: System Installed by
Certificate of Completion Date —
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
�.. .
: �• '. DAVIE COUNTY HEALTH DEPARTMENT
:
� ' � IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION , "
"�Note: Is"sued�in Compliance with G.S. of North Carolina Chapter 130—Article 13c. �, �
; . ��,�;- � ,�.�� r ,,;-G; . . Permit Number -
�lame rF t=.'�"',1f� ;��; � ���z:� tl�i� ; ;� z :.Date ' . f t . � � ,�A�,�
� ;����.�'�
,;Location {3�i� C../7 _:t'� �C(c^,S-:i �l i?<,,.. _ j=cail x:. �i'; c. �C: f;?:��,1� I�re t i,� —
Subdivision Name Lot No. _ Sec. or Block No.
Lot Size House Mobile Home — Business Speculation
4.
No. Bedrooms No. Baths No. in Family �
Garbage Disposal YES ❑ NO 0� Specifications for System: !��v�����°`s �`" �-
Auto Dish Washer YES pp NO p . � ��
Auto Wash Machine YES � NO �❑ "�,���� �' " �� !� `����Jx
Type Water Supply �`�4�'���' _ �� - 13��.� n�, c���,�t :r�
*This permit Void if sewage system�described below is not installed within 36 months from date of issue.
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Improvements permit by --���'�`` �
--�---- —
*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 day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by " " . �
.
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. ,-:_, ;�
Certificate of Completion � _ '�� r Date
"The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
•.J . I•
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
� Mocksville, N.C. 27028
S�IL/SITE EVALUATION
tvame �j 3vlZ�FtA-(L�— Date 3' y9 _ �3
Address ��� ��Nw�� ���� Lot Size �3� � ��
/1Mt��3✓ic,��--- /�/•�
l
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position . S S S S
� /�9 � PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S � S
Loamy, Clayey, (note 2:1 Clay) � � PS
� U ' U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils � � � PS
� U U U
4) Soil Depth (inches) g S S S
� � � � PS
� U U
5) Soil Drainage: Internal � � � S
pg PS � PS
U U U U
External � PS � PS
PS
� U U U
6) Restrictive Horizons
�
7) Available Space � S
PS PS PS PS
� U U U
8) Other (Specify) S S S S
PS PS ' PS . PS
� U U U
9) Site Classification
,
U—UNSUITABLE S—SUITABLE PS—Provisionaliy.Suitable � v
Recommendations/Comments: �K�� �i�"" �
Described by ��'�S Title �'�«�L'�'� Date 3����
SITE DIAGRAM � . .
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.� `• APPUCATION FOR�,SITE EVALUATION/IMPROVEMENTS PERMIT
„�Davie County Health Department
Environmental Health Section
P. O. Box 665
- Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone ��� —`3��$
1. Permit Requested By �a�� �� �V ry ha r"� `��� Business Phone�� — 5� i g
2. Address �n uJ �j�'G 'C� Q �'Y �: �
H Gt(I^�" /-) �
3. Property Owner if Different than Above ��-7"�r `�'1'��
Address �
4. Permit To: a) Install Alter Repair
b) Privy Conventional �her Type � -
Ground Absorption -
c) Sub-Division Sea Lot No.
5. System used to serve what type facility: House Mobile Home Business
� Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House 4.�mensions (n� X '��
Bed Rooms.�Bath Rooms�Den w/Closet �
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
.
; commodes �� urinals garbage disposal
lavatory �.� showers / washing machine � �
dishwasher � sinks ��
I
8. a) Type water supply: Pubiic Private�Community
b) Has the water supply system been approved? �es No�_L�
9. a) Property Dimensions���1�� � � � � �� / '
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /✓�
� What type?
This is to certify that the information is correct to the best of my knowledge.
�' � ls 3 � �
Dat Owner Signature ,
' OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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, �----____ .
DCHD(6-82) , ` . �
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"�� ' DAVIE COUNTY HEALTH DEPART."lENT
SITE EVALUATION CONSEIdT FORM
INSTRUCTIOTIS/PREREOUISTES
1. Camplete ths farm below and return it ro the Davie C�. Health Department.
_ 2. Along with �che f�rr.1, remit ths amount dus as shown an enclased stat2ment.
3. Carefully follaw the procedures as outlin�d in �che 2nclosed "Infarmazien
BuZletin".
4. Ydotify Heal�i:h Department up�n c�mple�cion of icQm nur.�ber 3.
NOTE: ALL THE ABOVE PdUST BE DOPJE BEFORE A SANITl�RIAPa irJILL BE ABLE
TO BEGIN THE REQUESTED EVALUATIOTI.
DETACH HERE AND RETURN TO THE(DAVIE COU1rlTY HEALTH DEPARTrIENT,P.O. IIOX 57)
• (!'iOCKSVILLEr 1ti1.C. 27028)
DAVIE COUNTY HEALTH DEPARTN�ENT
SITE EV,ALUATIOPI COYdSENT FOR1uI
IACATION OF PROPERTY: .,� " ' DATE RECEIVED
(� !,� �z.�� �/�,a�0� '»� ��C�o,� (offiae use dnly)
�
i�Q�-�C' �'' ���..� �
�.
yes n�1.) I am the awn�r of the abava descri.bed property.
�._1 `__ .!
y2s �o (2.) I �n not the ownar of the above de,�cribed prop� er�c�, hawever, I
{�j� certify that = have cons�nt from���ji �. ��,�,;Qs ati ,owner to
Y.,j � awnar's nanza
obtain a site evaluation by tha� healich Departm�nt fer the purpose
Qf determining the suitability far a graund absorptian sew�ge
disposal syster�z.
yes no (3.) I har�by giv� consent to th$ authorizad representative of the
� . ��' Davie County H�alth Department ta enter upon the above dascribed
property and conduct all t�stinq pracedures necessary to
determine its suitability for a graund absorption sewage
disposal sys�em.
� �
�.�,,.� � � c�3 ./' v '
�'
DATE SIGNATURE
(4.) I hereby authorize tha Davie County Health Department to ralease
si�e evaluation rasults from the abave described property to the
follczwing: '
� Owner Only
��L� l� /� �� � Own�r's designated repr�sentative
/ , ��Anyane requesting resulzs
DATE [� Only thase listed below
, .%` ��/' •
sicNAxuRr.
Pazcel#: K80000000103 , Page 1 of 1
o��1�
Davie County, NC - Basic Estate Search � ' t�
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View Pro�ertv Record for this Parcel View Mao for thls Parcel View Tax Bill Information
Parcel#:K80000000103 Account#: 11620000
Owner Information Tax Codes
RKHART EDWARD D]R&BURKHART MARTHA JEAN ADVLTAX-COUNTY TA
583 US HIGHWAY 64 EAST READVLTAX-FIRE TAX
DVANCE NC 27006
Pro e Information Townshl
nd(UNts/Type): 1.470 AC FULTON
ddress: 3583 E US HWY 64
Deed Information Local 2onin
ate: 04/1984 Book: 00122 Page: 0472
lat Book: Pa e:
Le al Descri tion PIN
1.53 AC HWY 64 5777654546
Pro e Values
uildin : 148 07
BXF:
nd• 23 75
Market: 171 82
ssessed: 171 82
eferred•
Sales Information
No. Book Paqe Month Year Instrument Qual/UnQual Improved Price
00122 0472 b4 1984 WD Un ualified Vacant 0
View Prooertv Record for this Parcel View Map 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 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 shouid be
consulted for verification of the information. All information contafned 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 inerchantability and fitness for a particular use.
If you have any questions about the data displayed on this webslte please contact the Davie County Tax Office at(336) 753-6120.
1.5.9
http://mavs.daviecountvnc.gov/itsnet/View.aspx?prid=1469733 6/21/2016