2273-A Hwy 64WDavie County Health Department
40 �;361 x 'ronmental Health Section ' • ,
G� P.O. Box 848
TO, 210 Hospital Street
O U 0� Q Q Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6 8���, ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680
(Check One) Replacement Remodeling Reconnection 4W bL.ASint-_-,5
Name: LILA Phone Number_ - (,O (Home)
Mailing Address: oS���`� /l (Work)
,�Q�O' QEmail Address:
To Site:
Property Address: /,3 ieB,6dt T_unAs
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility: BtL(L
T
Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant. Y s)No If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain: 0n1w I cLalr
>_
Please Fill In The Following n ormati n About The NEW Facility:
Type Of Facility: Bedrooms: Number of People
Pool Size: ize: Other:
Requested By: Date Requested:
(Signature)
� For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staf 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: rhof�Received By:
Account #: Invoice #: j 11-11
Davie County Health Department
P
4 1s bI`` Environmental Health Section
w- -
P.O. Box 848 .
.. 210 Hospital Street
1 Q 1`Z� _ Courier # : 09-40-06 1911
Mocksville, NC 27028
Phone: (336) - 753-6 780a- Fax: (336) -753-1680
ON SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection u S I' n t h
Name:. ( Phone Number r�� i CB %a s5� (Home)
T
Mailing Address:. // (Work)
Email Address:
��11�L1 rr )
Detail irections To Site: t \ L WtS eveI 4 CS G�
Property Address: 9.215-14 (T L-1 yj es % ;
llSlGf C —I—
i'(=
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: Type Of Facility: i
Data. System Installed (Month/Date/Year): Number Of Bedrooms:
Number Of People:
Is The Facility Currently Vacant. Y s No If Yes, For How Long?
`
Any Known Problems? Yes No If Yes, Explain:
onlu I P,t ("
WE L_ :..
Please Fill In The FollowinglM71 ' n About The NEW Facility:
Type Of Facility: uxnberTSf Bedrooms:
Number of People
Pool Size: .g ze: Other:
Requested By: 'Date Requested:
--(Signature)
- - - For Environmental Health Office Use Only
('Approved Disapproved.���
Comments
;
Environmental Health Specialist � r , ..(—f f ,� aj
Date:. /G�12�fr'
*The signing of this form by the Environmental Health StafVis. in no way intended, nor should be taken as a guarantee _
(ektended or limited) that the on-site wastewater system will function properly for any given period of time.
k
Payment:. Cash Check Money Order # Amount:$
Date:
Paid By:M — Received By: .�.
mnI
Account #:-' r� Invoice #:qJlI
S DAVIE COUNTY -HEALTH DEPARTMENTis-
- 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) Permit Number
Name A_ Z;Z;F Date /�%� 'h N2 � 4 10
,33
Location
Subdivision Name Lot No. Sec. or Block No.
LoY Size Zw f House Mobile Home Business � !/�pe�8/ulat onG`
No. Bedrooms!�
�_ No. Baths No. in Family
Garbage Disposal YES fl NO Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES ❑ NO
Type Water Supply Ira _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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:
f
Certificate of Completion 4 o 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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department ,meq
Environmental Health Section '� � l`•�'
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED._
/n� Home Phone
1. Permit Requested ByDG Business Phonct' t_� • /9(L�
2. Address - I G
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 2
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number f pe ns served 2._
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes i� urinals garbage disposal
lavatory V showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to iting site I/
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.
Dae Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: ' f D
DCHD (6-62)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name�Od CJIto Date
Address Lot Size h d�
FAGTOPR AREA I' AREA 2 AREA 3 ARFA 4
Topography/ Landscape Position
S
S
S
S
�9>.
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
(PSJ
PS
PS
PS
�j
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS.
PS
PS
U
U
U
) Soil Drainage: Internal
S
S
S
S
PS
PS
_ PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
S.
PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
--------------------
U—UNSUITABLE
Recommendations/Comments: 9, --�
S -SUITABLE PS—Provisionally Suitable
Described by��� Title Date
SITE DIAGRAM
P s
DCHD (6-82)
Parcel #: H30000001702
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 #: H30000001702 Account #:82527030
Owner Information
Buildin :
Tax Codes
BXF•
AR INTERNATIONAL INC
nd:
ADVLTAX - COUNTY TA
arket:
12 IVY PARK LANE
ssessed•
FIREADVLTAX - FIRE TAX
eferred•
INSTON SALEM NC 27104
65,000
3 00207 0551 11
Property Information
Qualified
Township
nd (Units/Type): 0.520 AC
4 00682 0404 10
CALAHALN
ddress: 2273 W US HWY 64
Improved
125,000
Deed Information
Local tonin
Pate: 10/2006 Book: 00682 Page: 0404
Plat Book: Page:
Le al Description
(— PIN
52 AC HWY 64
5719643511
Property Values
Buildin :
59,22
000111
BXF•
8110
nd:
22,74
arket:
90,06
ssessed•
90,06
eferred•
Cl
Sales Information
No. Book Page Month Year Instrument
Qual/UnQual
Improved
Price
L 00423 0866 06
2002 WD
Unqualified
Improved
15,000
2 00474 0564 04
2003 WD
Unqualified
Improved
65,000
3 00207 0551 11
1998 WD
Qualified
Improved
140,000
4 00682 0404 10
2006 WD
Qualified
Improved
125,000
View Property Record for this Parcel View Mao 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/itsnetfView.aspx?prid=1465564 7/14/2016