4244 Hwy 64W Ji
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) Permit Number
Name r �_ Date
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 'PQ
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO p Lj L) G
Type Water Supply --
"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
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*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 ��
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as
Crtificate of_Completion ' "�=�' Date
"The signing of this certificate shall indic a that the' system des ribed above has n installed in compliance with .
the standards set forth in the above regulation, but shall in NO wad be taken as gua�aitee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER
Davie County Health Department
Environmental Health Section b 16*1
P. O. Box 665
Mocksville, N.C. 27028
� J
' CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS13EEN ISSUED.
//►► ` Home Phone W g.-- 2_3$?
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1. Permit Requested By 7" 10 Ar2.�ryi-- 2 Business Phone 13 Y" -3.1r6l
2. Address &2y-/3 1`I 1 Adfs uil�c raC r2 '?o��Y
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-%Z� Alter Repair
b) Privy—f—/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 %X0Ai 0 w Q
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions &Wo_7- )6-rl gd o s�"t
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 O garbage disposal
lavatory showers. washing machine
dishwasher 1 sinks 2
8. a) Type water supply: Public—,PrivateCommunity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions tuykw94-AA) -'S AC-ay"
b) Land area designated to building site 4A< <- gfvfe r-t-I1' lx-A
C) Sewage Disposal Contractor -SI-Po -A
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? K3 6t,'
What type?
This is to certify that the information is correct to the best of my knowledge.
t
Date 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)
DAVIE COUNTY HEALTH DEPARTMENT
74, ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: �1jaf\tVitj 6LJ DATE RECEIVED
cA,es{- of G� Nt't 5 Sew-vl4t 6_-dt2 (office use only)
es no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system. .
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
_ZOwner only
Owners designated representative
Anyone requesting results
Only those listed below
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
i Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
---=a ---• - SOIL/SITE-EVALUATION
Name c' .. � Date 5�
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils' PS PS
U U U U
4) Soil Depth (inches) q) S S
S PS PS PS
U U U U
5) Soil Drainage: Internal C:i-'� S S
_ PS PS
U U U
External S S
ct3 PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
PS PS PS
U U U U
8) Other(Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by `• Title � Date
SITE DIAGRAM
L1
DCHD(6.82)
Parcel#:J100000017 Page 1 of 1
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Parcel#:3100000017 Account#: 14169000
Owner Information Tax Codes
RTNER TONY A&CARTNER ANN F ADVLTAX-COUNTY
E�2'44
T
US HIGHWAY 64 WEST EREADVLTAX-FIRE TAX
CKSVILLE NC 27028
Property Information Township
nd(Units/Type): 38.880 AC CALAHALN
ddress:4244 W US HWY 64
Deed Information :9
Local tonin
Pate: 03/1986 Book: 00130 Page:0407
Plat Book: Page:
Le al Description PIN
8.880 AC US HWY 64 WEST 4798623957
Property Values
uildin : 23414
BXF• 62,75
nd• 272,22
arket• 569,11
essed• 342,83'
eferred• 226 28
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
00130 0407 03 1986 WD Unqualified Improved 0
00110 0407 03 1986 WD Qualified Improved 40,500
View Prooerty 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 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=1479316 7/5/2016