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161 Macy Langston Lnr w . 'n.; .,.,,,. ..:i,i-v.i". e,....:• •.,.. we:ts.+.-...i.� 3 "✓ i ::..,. ,r;a � � .. Y_.- 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. `' > Date Location 1 Subdivision Name Lot No. Sec. or Block No. Lot Size 1% '�, House �- Mobile Home — Busine' s Snerulstinn No. Bedrooms No. Baths - No. in Family _ Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ Auto Wash Machine YES 0, NO '❑ V Type Water Supply _ C `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 System Installed by 1;F0 A Certificate of-Comple��ipn- i—'-'�-- Date c� c p I "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. 1 t 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 1;F0 A Certificate of-Comple��ipn- i—'-'�-- Date c� c p I "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 Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 11 Home Phone jo��3��93 1. Permit R e q u e s t e d Bye- 41,4 r �'/ Se� Business Phone 2. Address s e Id o2 3. Property Owner if Different than Above Address 4. Permit To: a) Install-ZAlter Repair b) Privy-ZConveritional Other Type Ground Absorption q, 01 c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House V" Mobile Home Business Industry Other b) Number of people 6. ar If house or mobile home, state size of home and number of rooms. House Dimensions a �% s6r1 Bed Rooms_ J Bath Rooms— Den w/Closet 0 b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) kaygg /'&100"y � �- /fie o�► 1 l'- 7. Number and type of water -using fixtures: commodes urinals garbage disposal lavatory showers washing machine / dishwasher sinks % 8. a) Type water supply: Public V/ Private Community b) Has the water supply system been approved? Yes No -Z 9. a) Property Dimensions 4 75 X AOS -a • 7 X .2.37 a % XC loZ % �5� %• b) Land area designated to building site 3_S )� iy 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 property: o- S o ��-�-Q.�� ,� Gam• C�� , �,�� a.�,r,.,, , DCHD (6-62) M r 1 31 a IT. 2 2 , 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) 4u -e Co. yes 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 conduct all 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 resu from the above described property to the following: Owner only — Owners designated representative Anyone requesting results Only those listed below DATE SI NATURE DCHD (11 /84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name— A Soo Date Address Lot Size c"T R i FArTnR.q AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/ Landscape Position S S ® S PS U U U U �) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Z:Tay) A? S <fD S PS U U U U 3) Soil Structure (12-36 in.) Clayey Soils PS S ®PS S PS S U U l) Soil Depth (inches) t) S S <39D S PS U U U i) Soil Drainage: Internal, S ® �S � (:ff: S PS U U U U External S ,� S� S PS U U U U i) Restrictive Horizons j Available Space PS PS PS S PS U U U U I) Other (Specify) S PS S PS S PS S PS U U U U: 1) Site Classification PS ?5 S U—UNSUITABLE S—SUITABLE PS— rovisionaliy Suitable Recommendations/Comments: Described by �.w ��- Title *�-� Date 6 SITE DIAGRAM % VCMO (6-82) Parcel #: D30000003601 Davie County, NC - Basic Estate Search ,, Basic Search Real Estate Search Tax Bill Search Sales Search Q View Property Record for this Parcel View Map for this Parcel View Tax Bill Information Parcel #: D30000003601 Account #:80200560 Owner Information 117,66 000 Tax Codes 5,460 LSON RICHARD KEITH& WILSON JUDY LOONEY FOM16c, 50,08 ADVLTAX - COUNTY TA 173 20 1 MACY LANGSTON LANE 173 20 READVLTAX - FIRE TAX CKSVILLE NC 27028 Property Information Townshi Land (Units/Type): 5.000 CLARKSVILLE ddress: 161 MACY LANGSTON LN Deed Information Local Zoning —, Date: 06/1988 Book: 00143 Page: 0715 Plat Book: age: Le al Description PIN WY 601 80200560 Property Values Buildin : 117,66 000 BXF• 5,460 Land: 50,08 Market: 173 20 ssessed: 173 20 Deferred: Sales Information No. Book Page Month Year Instrument Qual/UnQual Improved Price 1 00143 0715 06 1988 WD Qualified Vacant 13 500 View Property Record for this Parcel View Map for this Parcel View Tax-Bilt Information « Return to Basic Search Page 1 of 1 AIXr� 1-0 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/itsneWiew.aspx?prid=1460058 8/24/2016