3332 Hwy 801SDavie County, NC Tax Parcel Report I � O `+ 6-q Tuesday, September 27, 2016
389
Tot
3332
4287
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A
141
Davie County, NCimplied
WARNING: THIS IS NOT A SURVEY
causes of action due to or arising out of the use or inability to use the GIS data provided by this website.
arceflnformation
Parcel Number:
180000002801
Township:
Fulton
NCPIN Number.
5788144287
Municipality:
Account Number:
82514383
Census Tract:
37059-804
Listed Owner 1:
BARNHARDT J TODD
Voting Precinct:
FULTON
Mailing Address 1:
3332 NC HIGHWAY 801 SOUTH
Planning Jurisdiction:
Davie County
City:
ADVANCE
Zoning Class:
DAVIE COUNTY R-A,R-20
State:
NC
Zoning Overlay:
Zip Code:
27006-0000
Voluntary Ag. District:
No
Legal Description:
4.83 AC OFF HWY 801
Fire Response District:
FORK
Assessed Acreage:
4.81
Elementary School Zone:
CORNATZER
Deed Date:
4/1999
Middle School Zone:
WILLIAM ELLIS
Deed Book/Page:
002110267
Soil Types:
PcB2
Plat Book:
Flood Zone:
x
Plat Page:
Watershed Overlay:
WS -IV -P
Building Value:
379640.00
Outbuilding & Extra
7440.00
Freatures Value:
Land Value:
53400.00
Total Market Value:
440480.00
Total Assessed Value:
440480.00
141
Davie County, NCimplied
All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the
warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold
harmless the County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or
causes of action due to or arising out of the use or inability to use the GIS data provided by this website.
NAY
w Davie County Health Department
�s I� Environmental Health Section
P.O. Box 848
210 Hospital Street
Courier # : 09-40-06 R 1911
Mocksville, NC 27028
Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680
(Check One) Replacement Remodeling Reconnection
c /
Name: / U/-" 1,� Phone Number ?C (Home)
Mailing Address. / d lli'r-ff �h �� = %j`0 F� C,
-�ql (Work)
lar 'Ile 7 %O 2 Email Address: _dells ci S5 Gi•'o�� G� tai gf� �
Detailed Directions To Site: /)/w,/ (, e S 7 i? 0f 5 C T U r h e -
Property
Please Fill In Theme to lawin ation on Fa�tCi c
Name System Installed Under:. itl h i`1 Type Of Facility:.S�/
Date System Installed (Month/bate/Year): 706/ Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? Yes �No� If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facilitk: .3(o k 5�d l�r f �c �-/ (-rr, e- Number Of Bedrooms:_oNumber of People
Pool Size:42 4
/ GG ge Size: ? -�'O Other:
Requested By:T Date Requested: Z— L?
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health S ecialis( l,,. d-1 Date: % 22, 2
*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.
9
Payment: Cash Chec Money Order # 7i Amount:$ 00 Date: a i
Paid By: C ubb Received By:
Account #: d �Cf qo o6 5 7 Invoice #:;' '
`x
Appraisal Card
r
Page 1 of 1
DAVIE COUNTY NC
I00
3/15/2013 9:43:41 AM
ARNHARDT 3 TODD BARNHARDT SUZANNE E
Retum/Appeal Notes: I8-000-00-028-03
50011
332 S NC HWY 801
(S)39dd NOIivdnQ 3WCN/rON Xdd
UNIQ ID 17380
31Va
2514383
D476 -P14 ID NO: 5788144287.
COUNTY TAX (100), FIRE TAX (100)
CARD NO. 1 of 1
eval Year: 2013 Tax Year: 2013
4.83 AC OFF HWY 801
4.840 AC SRC- Inspection
kppralsed by 02 on 08/30/2007 04001 FULTON
TW -04 C- EX- AT- LAST ACTION 20120517
CONSTRUCTION DETAIL
MARKET VALUE
DEPRECIATION CORRELATION OF VALUE
oundation - 3
Standard 0.1200 -
ontinuous Footing5.0
Eff.
MO Area UA]BASE
RATE
RCN EYB AVB CREDENCE TO MARKET
ub Floor System - 4
US
01 3 548 142 99.40
355372 20012001 % GOOD 1 88.0 DEPR. BUILDING VALUE - GRD
312,730
ood 8.00 01
xterior Walls - 21
TYPE: Single Family Residential
Single Family Residential DEPR. OB/XF VALUE - GRD
7,44
ace Brick
34.00
MARKET LAND VALUE - GRD
53,40
oofing Structure - 06
STORIES: 2 - 1.5 Stories
TOTAL MARKET VALUE - CARD
373,57
rre ular/Cathedral
13.0
oofing Cover - 03
ksphalt or Composition Shingle
3.00
TOTAL APPRAISED VALUE - GRD
373,57
nterior Wall Construction - 5
TOTAL APPRAISED VALUE - PARCEL
373,57
)rywall/Sheetrock
26.0
nterlor Wall Construction - 6
ustom Interior
0.0TOTAL
PRESENT USE VALUE - PARCEL
nterlor Floor Cover - 12
TOTAL VALUE DEFERRED - PARCEL
ardwood
10.0c
OTAL TAXABLE VALUE - PARCEL
373,57
nterlor Floor Cover - 14
'arpet
0.0c
PRIOR
eating Fuel - 04
-
UILDING VALUE
344,83
lectric
1.0 +16-+
BXF VALUE
10,92
+6+ I
AND VALUE
52,66
eating Type - 10
6 F U S I
RESENT USE VALUE
eat Pum -
4.0 +6+ 3
EFERRED VALUE
it Conditioning Type - 03
I 0
rOTAL VALUE
408 41
4.0 1 Ims/Bathrooms/Half-Bathrooms
19.00 +16-+
ms
+13-+16-+
3FUS-ILL-I
1FOP1WDD1
PERMIT
oms
4 4 4
CODE DATE NOTE NUMBER AMOUNT
2FU5-iLL-1
+11+13-+16-+-16-+
+----40----+-16-+
athrooms
IBAS I
IFBM IBUG I
[entral
2 FUS- 0 LL -0
I1
1 1 I OUT: WTRSHD:
L POINT VALUE
127.00 1 3
4 2
6 3 3 SALES DATA
+--24--+ 2 2
BUILDING ADJUSTMENTS
0 I
IUBM I I I FF' INDICATE
3 Size
0.890 I I
2 2 I IRECORD ATE DEED
SALES
4 ABAVG
1.200 I +9-+14-+
4 1 +7+-16-+ OK AGEM R TYPE /PRICE
/Desi 4 FACTOR 4
1.050 5 F O P
I I S 0211 267 4 199 WD U V
2500+--24--+9+9-+
+--24--+9+
ADJUSTMENT FACTOR
1.12 - IFGD I
QUALITY INDEX
14 1 1
2 2
4 .. 5
HEATED AREA 3,486
I I
+12+12-+
NOTES
US -B&B OVER FGD&BAS THAT
OU ENTER FROM BAS AREA
SUBAREA
UNIT
ORIG % ANN DEP % OB/XF DEPR
TYPE GS AREA % RPL CS ODE DESCRIPTIO LT NIT PRICE
GOND LDG B AYB EYB RATE Vill CON.
VALUE
5 2,021) 10 20168
9 P PAVING 1 50 5,00 3.0
_ L 001 001 S 4
6000
UG 51 02 1272 30 ON PAVING 2 3 60 4.0
L 00 00 5 6
144
BM 941 04 4204
OTAL OB XF VALUE
7,440
GD 58 04 26341
OP 22 03 785
us 516 09 46122
T
BM 57 02 11431 Eli
J( �✓/ /J J�j f //
DD 1 2241020 447
/
3 - 1 Story
.
IREPLACE Sln le 2,70
USAREA'
OTALS 5,61 55,37
UILDING DIMENSIONS BAS-W16WDD=N14W16S14E16$W16FOP=N14W13514E13SW24S40FGD=S24E12SIE12N25W24$E24N3E9F 23N32S E15
BM-E40BUG-E16S32W16N32 S32W7SSW9UBM-N21W24S24E24N3 N21W24N16 W15N20W40FUS=N30W16S6W6S6E6SI8EI6 E40S204S7 ..LL
ND INFORMATION
OTHER
LAND TOTAL fir]
jUIGNEST r�y�'�`
ND BEST
USE
LOLL
FRON
DEPTH/
LND
COND
ryNV�j�pp�C`j7j7
ijT����I URIC
LAND
SE
CODE
ZONING
TAGE
EPT SIZE
MOD
FACT
P
(lA�']Np_]
VALND
PM14CE1 UE
NOTES
URAL AC
0120
332
01 1.3100
4
1.1700
Ol +16 +00 +00 +00 pW
7,200. 11, 5340
ca en
OTAL PRESEN SE I 1ATA J,%SFjEj I
I00
E0
50011
1N3WW00 rm3d
(S)39dd NOIivdnQ 3WCN/rON Xdd
3WI1
31Va
'ON
8LE8ZIM000 : #*83S
08916SL9EE : X31
08916SL9EE : XV -1
H30Q : 3WdN
10:00 EZOZ/ZZ/E0 3WI1
iWdMl IVN no XB3
http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parcel=I80000002801 3/15/2013
3305-`-
_
3307 .�.
f 4 3311,
r j
All data is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the implied G �,
C+
warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of
Davie, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of Pri nted: M a r 13 2013
5 the use or inability to use the GIS data provided by this website. r
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Bog 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900458 Tax PIN/EH #: 5788-14-0379.000E
Billed To: Todd Barnhardt
Reference Name: Suzanne Barnhardt
Proposed Facility: Residence
ATC Number: 2601
Subdivision Info:
Location/Address: 801S.-27006
Property Size: 5 acres
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by 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 WASTEWATE CONSTRUCTION IS VALID FORXAOD OF FIVE YEARS.
Environmental Health Specialist's Signature:
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 guarantee that the system will function satisfactorily for any
given period of time.
Septic System Installed By: /` 11(L
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
Date:
DAME COUNTY HEALTH DEPARTMENT
- . T Environmental Health Section f6t j 06
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900458 Tax PIN/EH #: 5788-140379.000E
Billed To: Todd Barnhardt Subdivision Info:
Reference Name: Suzanne Barnhardt Location/Address: 801S.-27006
Proposed Facility: Residence Property Size: 5 acres
** aj*VyVbgr. 2601
N is mprovement/Operation 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 #People% #Bedrooms #Baths_
Dishwasher: Garbage Disposal:Z Washing Machine: 2T' Basement w/Plumbing: P?"' Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
Lot Size Type Water Supply b Design Wastewater Flow (GPD) �fT( Site: New M/ Repair ❑
System Specifications: Tank Size/.2
gP GAL. Pump Tank GAL. Trench Width Rock Depth 19I Linear Ft.�'
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1:00 p.m. to 1:30 p.m. on th f installation. Telephone # is (336)751-8760.****
0'r, LlAed
SGV
Environmental Health Specialist's Signature: Date: /l9
DCHD 05/99 (Revised)
r
• A• • ' ' APPLICATION FOR SITE EVAWATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department D
Environmental Health Section OCT
P.O. Box 848/210 Hospital Street 2000
Mocksville, NC 27028
(336)751-8760
5 ��z'� e- a_ J y /
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refei to the INFORMATION BULLETIN for instructions.
1. Name to be Billed
Mailing Address
City/State/ZIP
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For: ❑ Site Evaluation
4. System to Service: C#/HOuse ❑ Mobile Home
S. If Residence: # People
Contact Person 1 (.1L!U h " /
Home Phone 75Q--
Business
/Business Phone nUl_J lad- —
City/State/Zip
Improvement Permit/ATC ❑ Both
❑ Business ❑ Industry ❑ Other
# Bedrooms # Bathrooms 1'
0 Dishwasher a Garbage Disposal b washing Machine A Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/Other: SpeLify type # People # Sinks' -
# Commodes # Showers # Urinals # water Coolers
IF FOODSERVICE: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: 111 County/City
9. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ co= mnity
❑ Yes FVNo
j ***IMPORTANT*** CLIENTS MUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED I
I BELOW. Either a PLAT or SITE PLAN MUST BESUBMITTED by the client with THIS APPLICATION.
Property Dimensions: nti—� CSC/ ']WRITE DIRECTIONS (from Mocksville) to PROPERTY:
Tax Office PIN: # l I� U►
Property Address: Road Name / on
City/Zip
If in a Subdivision provide information, as follows:
Name: i
Section: Block: Lot: Date Property Flagged: I 0
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter 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. 1, also, understand that 1 am responsible for all charges incurred from
this application. I, hereby, 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 sbility.
DATE I V SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Site Revisit Charge
Date(s):
Client Notification Date:
EHS•
Revised DCHD (07/99)
q -1l
711Jt� �ra[7�
Account No. p
Invoice No. o �y
U
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PE
Davie County Health Department
Environmental Health Section TrFEB g0 P.O. Box 848
Mocksville, NC 27028
�F
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed / a A- r/fJa r1; 4aM �'" Contact Person � � 9,4 /moi? 441 y
Mailing Address ��f� Gt/ Home Phoneme '7S�g—
City/State/Zip I /D Business Phone
2. Name on Permit/ATC if Different than Above :57-q L-
Mailing Address ioLll� City/State/Zip
3. Application For: [Fite Evaluation [ ] Improvement Permit & ATC [ ] Both
4. System to Serve: YJ House [ ] Mobile Home [ J Business [ ] Industry [ ] Other
5. If Residence: # People—3— # Bedrooms 3 # Bathrooms [ ishwasher [✓) Garbage Disposal
[ FIV*ashing Machine [ ] Basement/Plumbing [ qCasement/No Plumbing
6. If Business/Other: Specify type # People #Sinks # Commodes
-
# Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: 141county/City [ ] Well [ ] Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? [' ] Yes [4
If yes, what type?
EITHER A PLAT OR SITE PLAN
PROPERTY INFORMATION REQUIRED: *** IMPORTANT **%tT1 T OF THE PROPERTY MUST BE
,QCQ✓ SUBMITTED WITH THIS APPLICATION.
Property Dimensions: '29G• 3 a-- X "' 7,5;cpWPdTE DIRECTIONS (from Mocksville) TO PROPERTY:
Tax Office PIN: # -�� - ��3� 9 f(a0��'/� •� Hwy �D/ Ge,�f
Property Address: Road Name AK FO/ S K � 14 �" S%d �ih�sr a
City/Zip W,41A 464 AIC
If in Subdivision provide information, as follows: 001"1L WA3e- Z62,�
Name: 1JIX
Section: Lot #: / /t Q MTS J F4d 4-&6Y'' �/7 �—
(Tn iN C, -
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter 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, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized
Represe tative of the avie ounty/Health Department to enter uponfabovescrib
to con ct 1 t 'nes as
DATE o`t- SIGNATUR
Revised DCHD (06-96)
THIS AREA MAY BE USEb FOR DkAIVING YOUR SITE PLAN:
property located in Davie County and owned
,essary to determine the site suitability.
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DAVIE COUNZ
TAX MA
f . - DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME
PROPOSED FACILITY
SUBDIVISION
Water Supply:
Evaluation By:
On -Site Well Community
Auger Boring Pit
DATE EVALUATED 565 1317-61
PROPERTY SIZE
ROAD NAME A-Lj'i9
mi S
Public
Cut
SITE CLASSIFICATION: EVALUATION BY:
l
LONG-TERM ACCEPTANCE RATE: �.35 OTHER(S) PRESENT:
REMARKS:
DCHD (01.90)
LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC:- Concave slope CV - Convex slope T - Terrace 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 - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
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)
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 - gal/day/ft2
Landscape position
HORIZON I DEPTH
- . owl •
HORIZON 11 DEPTH
Consistence
HORIZON III DEPTTexture
••�'�l�Si71/�[i�--�
group
•
i�1i�4'l��-1'
---
Consistence
.Tam
Mineralogy
Texture group
Consistence
CLASSIFICATION
SITE CLASSIFICATION: EVALUATION BY:
l
LONG-TERM ACCEPTANCE RATE: �.35 OTHER(S) PRESENT:
REMARKS:
DCHD (01.90)
LEGEND
Landscape Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC:- Concave slope CV - Convex slope T - Terrace 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 - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
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)
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 - gal/day/ft2
■
no
ME
on
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Davie County Wealth Department
Environmental Neal th Section
PO Box 848 / 210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
March 26, 1999
Mr. Todd Barnhardt
1846 Waycross Drive
Winston-Salem, NC 27106
Re: Site Evaluation -
5 Acre Tract/Hwy 801 S
Tax PIN #: 5788-14-0379
Dear Mr. Barnhardt:
As requested, a representative from this office visited the aforementioned site on
March 24, 1999. Based on the information provided on the Application for Site
Evaluation and after the evaluation was completed, the site was found to be provisionally
suitable for the installation of an on-site sewage disposal system.
**SPECIAL NOTE: Due to some complex topography on this tract, the area available
for installation of the system is limited. Additionally, placement of the house may require
setting a pump station.
Before a representative of this office will revisit the site to issue an Improvement
Permit/Authorization to Construct, the appropriate application must be completed in full
and submitted to this office. The location of the facility the system is to serve must be
staked off.
enc(s)
If you have any questions, you may contact our office at (336)751-8760.
Environmental Health Section
FROM.: BARNHARDT
___ FAX NO. : 336-940-3934
v
County Health- Department
Onmental-Health •Section •
3 '��
P.O. Box 848
210 Hospital Street
Courier #: 00-40-06
C UN FAw,
Mocksville, NC 27028
Jul. 02 2007 11:20PM P1
ON-SITE WASTEWATER CERT N FOR DWELLING
(Check One) Replacement Remodeling Reconnection
j�
Name: ilanfttC &AladT __..1%one Nvmbcr. •
Mailing Address tt' 1� :A (Work}
tt
5itc: 1� 4 t 6 k1041
r `J GU
D- n,-9 4 tr rt YF tr<la,tf • (AUC- end •k� a Av a
Fax: (.336) - 751- 8786
Detailed Directions To
Pmlx:rty Addtuss'c!
Please Fill In The Followin Information About The EXISTING Facility:w4 I %
Name System Installed Under: I }� l2 Type Of Facility:�2:S{y de
Date System lastalted (Month/Date/Year): Number Of Redrooms;..5_Numbcr Of P optc:�.
Is The Facility Currently V=at? Yes No If Yes, For How Long?
Any [Gown Pxobtema7' Yes ' 1f Yes, Cxplain:
Please Fill In The Foll ; rii Information About The NEW Facility:
Type Of Facility: Requesv um erof People
Requested By: 4 rL a e 'P Date ted: 6
For Environmental Health Office Use Only
Appmvea Diwx ovcd •
Comments:
Environmental Health Specialist Date:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee-
(extended
uarantee(extended or limited) that.the on-site wastewater system willfunction properly for any given.period of time.
Payment: Cash Check !Money Order # Amount:S Date:
Paid By: ----Received By:'
Accountl�: 34 Livaicn#:
FROM.: BHRNHmRDT
FAX NO. : Jul' 02 2007 11:20Pn P2
x
�
K
DAME COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Boa 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
Account #: 989900458 Tax PIN/EH #: 5788-140379.000E
Billed.To: Todd Barnhardt Subdivision Info:
Reference Name: Suzanne Barnhardt Location/Address: 801S.-27006
Proposed Facility: Residence Property Size: 5 acres
ATC Number: 2601
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by 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 WASTEWATE CONSTRUCTION IS VALID FORZte:
OD OF FIVE YEARS.
Environmental Health Specialist's Signature: > � le '%e�
r
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 guarantee that the system will function satisfactorily for any
given period of time.
0 1)- -
Septic System Installed
Environmental Health Specialist's Signature:
DCHD 05/99 (Revised)
I
Date:
LAvm riEAL'1'H DEPARTMENT
Environmental Health Section %
P. O. Boz 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
IMPROVEMENT/OPERATION PERMIT
Account #: 989900458 Tax PIN/EH #: 5788-14-0379.000E
Billed To: Todd Barnhardt Subdivision Info:
Reference Name: Suzanne Barnhardt location/Address: 801S.-27006
Proposed Facility: Residence Property Size: 5 acres
** �T*l�lbgr: 2601
N is mprovement/Operation Permit DOES NOT authorize the constructionof 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#People_ #Bedrooms #Baths
Dishwasher: ❑ Garbage Disposal:z Washing Machine: Basement w/Plumbing: P""' Basement/No Plumbing: ❑
Commercial Specification: Facility Type #People #People/Shift #Seats Industrial Waste: ❑
i
Lot Size t . Type Water Supply 14t Design Wastewater Flow (GPD) U Site: New . Repair ❑
1
System Specifications: Tank Siz%Z GLS GAL. Pump Tank GAL. Trench WidthL, Rock Depth /Linear Ft.JaL
Other:
Required Site Modifications/Conditions:
IMPROVEMENT/OPERATION PERMIT LAYOUT - APPROVED EFFLUENT FILTER RISER(S) IF 6 " BELOW
FINISHED GRADE. ****NOTICE: Contact a representative of the Davie County Health Department for final inspection of this
system between 8:30 a.m. to 9:30 a.m. or 1.00.m. to 1:30 p.m. on th f installation. Telephone # is (336)751-8760.****
8 6 i1 flr,v 1.
-0j)
ed
X
Environmental Health Specialist's Signature: Date:
DCHD 05/99 (Revised)
t
Davie County Health Department ea//
Environmental Health Section jo�q
P.O. Box 848
• d
21.0 Hospital Street
Courier # : 09-40-06
Mocksville, NC 27028
/ae
Plione: (336) - 753 - 6780 Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name: Jir��4te.,t7L Phone Number 334' / "7 (Home)
Mailing Address: 3332: NC 6/y Fd% SoUltIlp �%If- /n� (Work)
cc -/1k, 0_70a
Detailed Directions To Site: 6 / 6e, ST _�v Ilulty ;?d/ • _71l I'll Z e� d -A /_,/� 100%
-`Y 3 �, el
Property Address: me. as
Please Fill In The FollowingInformationAbout The EXISTING Facility:
Name System Installed Under: / Ol,� �_A ZakGte n tf` : Type Of Facility: u �-
Date System Installed (Month/Date/Year): '°' 004Z219 Number Of Bedrooms: Number Of People: 7
Is The Facility Currently Vacant? Yes C1;W If Yes, For How Long?
Any Known Problems? Yes / Nd If Yes, Explain:
Please Fill In The Following Ihformation.About The NEW Facility:
Type Of Facility: ak_�� a-- Number Of Bedrooms: Number of People
.Pool Size: N Garage Size:_5G }l zf 8 Other:
Requested By: Date Requested:
ignature)
For Environmental Health Office Use Only
Approved Disapproved
Environmental Health Specialist.
Date:
T
*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: Cashes Money Order #
Paid By:
eived By:
Account #: Invoice
('Z.` lilt .1 ... . I n l .o n i.
Date:
�Y1(