4557 Hwy 801Nr`-' ' `'" • DAVIE COUNTY HEALTH DEPARTMENT JSu o
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c ,
Sewage Treatment and Qisposal Rules (10 NCAC 10A .1934-.1968) Permit Number
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�-t �> > -Date 2 14 -'Z`> N2
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Location-,-�'-�`j (`���`. s ���� Av Com.
Subdivision Name Lot No. Sec. or Block No.
Lot Size 1^ House Mobile Home,_ Business Speculation
No. Bedrooms 'No., -Baths No. in Family
Garbage Disposal, YES p NO Specifications for System:
Auto Dish Washer` ',',.,,',YES E).NO y C) o o
Auto Wash Machine YES p NO Y 1 air
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
*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.
Certificate of Completion C. Date ��7_ 70
*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.
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asi}a "wiq 9 5 Lr.9-� y-:,. y-', '{ _ f . a.. .. . , . . "' ' `'" S t l"° ry iw `.s it �'.rC -.f 3. t ✓.1. v Iry >..E 1 ,-).,'tee. :J;+n dY K/:;.`.•'n
b 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 isposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Nam'c.�.t,N_ �c \-A :,7- « �,4,r `:�- ��' "LDate y
_21> N° 9
Location' v
<,<_;�
—
�� ^—__ .
--;subdivision Name "" " Lot No. Sec. or Block No.
dot Size House Mobile Home — Business Speculation
No. Bedrooms No., Baths No. in Family
Garbage Disposal, YES ❑ NO Specifications for System:
Auto Dish Washer` YES ❑ NO ✓{� / �� c> f, r, ~ i �' `'i �,'
Auto Wash Machine YES ❑ NO gi , n�� 3' X
Type Water Supply r� �, .� �_;'� �.., __
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
17
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:
Installed by C 4 z f, t*^ V- 0
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 give6 period of time. r
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:
Installed by C 4 z f, t*^ V- 0
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 give6 period of time. r
A APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
v' Davie County Health Department
w\ DECCEnvironmental Health Section ED
�\ P. O. Box 665 RECE�V
Mocksville, N.C. 27028 I�
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
l t Home Phone ��� 3 70
1. Permit Reque ted By + / r//� Business Phone -3,(/— .3:5-6/
2. Address % t� G - Z33
3. Property Owner if Different than Above if L/Le �WVST C&e1RCo1
Address ��X Z2r:
4. Permit To: a) Install Alte � 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-42ZI-41 H
b) Number of people /_P 10 – ZOO
6. aT 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 of persons served 7 -- T
What type-buskm", etc. ell,_ZI26 d
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes urinals garbage disposal
lavatory Z showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes k'No
9. a) Property Dimensions _? 'qcf,g_&-s
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to
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1 7- 0 AJ
DCHD (6-82)
1/rs/7-s f"2olegr7 , 50
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DAVIE COUNTY HEALTH DEPARTMENT
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: DATE RECEIVED
(office use only)
yesno 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 696�d */-- Li�TC 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 Departmentto enter upon the above described property and conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal ystem.
dF
-, 7 - ��&- "e'd 4 4
DATE GNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
_ 0nrners designated representative
_ Anyone requesting results
— Only those listed below
11Z. Ile, --
EW-
DATE
DCHD (11 /84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ` C-1 qyvl�
Address Lot Size
GerrrnQc eRFe-T"'� ARF� AARFA 3 ARFA d
Topography/ Landscape Position
9)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
I) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
Soil Depth (inches)
S
S
S
S
PS
PS.
PS
PS
U
U
U
U
�) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DjAGRAM
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DCHD (6.82)
Davie County, NC Tax Parcel Report Wednesday, August 31, 2016
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage:
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
Outbuilding & Extra
Freatures Value:
Land Value:
Total Market Value:
Total Assessed Value:
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a
X00 N�
C30000003501
5823226906
9730350
BREAD OF LIFE BAPTIST CHURCH
C/O PHIL KITCHIN
LEWISVILLE
NC
27023-0000
2.35 AC HWY 801
2.28
8/1988
001440521
650890.00
14370.00
WARNING: THIS IS NOT A SURVEY
Parcel Information
Township:
Municipality:
Census Tract:
Voting Precinct:
Planning Jurisdiction:
Zoning Class:
Zoning Overlay:
Voluntary Ag. District:
Fire Response District:
Elementary School Zone:
Middle School Zone:
Soil Types:
Flood Zone:
Watershed Overlay:
Clarksville
37059-801
CLARKSVILLE
Davie County
DAVIE COUNTY 1-1,R-20
No
COURTNEY
WILLIAM R DAVIE
NORTH DAVIE
MrB2,MsC
X
27250.00
692510.00
692510.00
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