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1607 Milling RdDavie County, NC Tax Parcel Report 46 3044 A Friday, September 30, 2016 All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davis, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to �pUN'ta NC or arising out of the use or inability to use the GIS data provided by this website. WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number: H60000002001 Township: Mocksville NCPIN Number: 5759242602 Municipality: Account Number: 82516180 Census Tract: 37059-805 Listed Owner 1: GRAHAM DAVID C Voting Precinct: NORTH MOCKSVILLE COUNTY Mailing Address 1: 1607 MILLING ROAD Planning Jurisdiction: Davie County City: MOCKSVILLE Zoning Class: DAVIE COUNTY R -A State: NC Zoning Overlay: Zip Code: 27028-0000 Voluntary Ag. District: No Legal Description: TRACT 1 MICHAEL KELLY S/D Fire Response District: CORNATZER - DULIN,MOCKSVILLE Assessed Acreage: 11.32 Elementary School Zone: CORNATZER Deed Date: 5/2006 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 006610076 Soil Types: GnB2,GnC2 Plat Book: 0008 Flood Zone: Plat Page: 298 Watershed Overlay: DAVIE COUNTY Building Value: 216800.00 Outbuilding & Extra Freatures Value: 22170.00 Land Value: 101050.00 Total Market Value: 340020.00 Total Assessed Value: 263460.00 All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS website shall hold harmless the County of Davis, North Carolina, Its agents, consultants, contractors or employees from any and all claims or causes of action due to �pUN'ta NC or arising out of the use or inability to use the GIS data provided by this website. . DAVIE'COUNTY HEALTH DEPARTMENT `(a Environmental Health Section PROPERTY INFORMATION pJ P.O. Box 838 Directions to property: �'�.( + ; U . 12 LL S'"O 16 Mocksville. NC 27028 Subdivision Name: !L Id�� (� i i t �i i ( Phone #: 336-751-8760 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# ..yy11 SYSTEM CONSTRUCTION ,3��i �%O]/rli.;�'.i 4 f1 Zi /(l,r AUTHORIZATION NO: A Road Name: Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Fonn/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pennits. (In compliance with Article I I of G.S. Chapter 130A. Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) , i.. ') ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ll V�i�L�it IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE : / ? # BEDROOMS '3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY; d' r4 (I DESIGN WASTEWATER FLOW (GPD) H NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE PUMP -TANK- GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT j S` !V Ofn FA tS ^ 70 -- i 1 (.27 FAA � Fx' L,oId 5 1 3a - do FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30.9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT SYSTEM INSTALLED BY: AUTHORIZATION NO_?�-I4-�'► OPERATION ATION PERMIT BY: DATE: V **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES R[BED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I I 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. DCHD =2 (Revised) Davie County Healdl Department O 1836 jc° Environmental Healdi Section -�'. ` P.O. Box 848 r",�„210 Hospital Street O N� Courier # : 09-40-0(i 1911 Dlocksville,NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 753-1680 ]]�� 11 (Check One) Replacement Remodeling Reconnection Name: D A o (A 4 1 i / l 14 1%( Phone Number/- yU7' 3 �y � � � S 6 (Home) Mailing Address: 1,667 , I i i N 9 5 "I'd q�?'%74(q (Wor ) Email Address: Zf, Detailed Directions To Site: Property Address: 1/ D Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: I + Date System Installed (Month/Date/Year): Number Of Bedrooms:Number Of People:_ I Is The Facility Currently Vacant? Yes No If Yes, For How Long? { Any Known Problems? YesIf Yes, Explain: Please Fill In The FllowingInformatidnAbout The NEW Facility: TU-i�(�1��eoVP/ ONS/ahOtPod—I Type Of Facility. �' Yu�n� n { Number Of Bedrooms: Number of People � T Pool Size: Gar '/ age Size: o? Other: Requested By: Date Requested: (Signature) I For Environmental Health Office Use Only / Approve Disapproved omrhents: I Environmental Health Specialist , aC uce13 it /a /(,r_l� � Date: *The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee j(extended or limited) that the on-site wastewater system will function properly for any given period of time. i i Payment: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account #: Invoice #: Davie County Health Department his ' Environmental Health Section i P.O. Box 848 210 Hospital Street O U 1; Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fax: (336) - 753-1680 Name: (� (% (' 94 411 l4 M Phone Number" clU7" 3 �Q'/ C / S 6 (Home) Mailing Address: / 6 ? %i?,' / / i�N y S /� L� %�iy (Wor ) X-C Email Address: 2 Detailed Directions To. Site: / S a Property Address: / � 6 7 A/ _S %TW Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: Type Of Facility: Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People:% Is The Facility Currently Vacant? Yes No If Yes, For How Long? Any Known Problems? Yes �fNfo) If Yes, Explain: Please Fill In TheF lowing Infor ati n About The NEW Facility: Tu -ii I it t) (lU V P r Type Of Facility: do 'l � Number Of Bedrooms: Pool Size: Garage Size:.20 �(C��i/Other: Requested By: (Signature) Date Requested: - — For Environmental Health Office Use Only f ove Disapproved ents: Number of People Environmental Health Specialist (I , )Jr zo X611CI c&_"_ ' Lf Date: *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: Cash Check Money Order # Amount:$ Date: Paid By: Received By:_ Account #: Invoice #: Pemnttee-s r DAVIE ,COUNTY HEALTH DEPARTMENT Name,L') ��� ' 0-A \Q Environmental Health Section PROPERTY INFORMATION C P.O. Box 848 �\ Directions to property: %'4 t °/ i Jt: +`P` -th`{, b1ocksville, NC 27028 Subdivision Name: (•'11(� :• j C`\ iii( iii, Phone #: 336-751-8760 r Section: Lot: I AUTHORIZATION FOR i1 LA(, �-1 �'�•tL',fl� �...(1 � ��'� ��f( � WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION AUTHORIZATION NO: A Road Name:0039411/ W7 /I i Zip:: f 1: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I I of G.S. Chapter 130A. Wastewater Systems, Section. 1900 Sewage Treatment and Disposal Systems) l /' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION l 1 ') �/'�6 �� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL H9ALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY 6161 (1 DESIGN WASTEWATER FLOW (GPD) aS (rte NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE - ( S rAt . PUMP -TANK --GAL. TRENCH WIDTH _5 G ROCK DEPTH /LL! % LINEAR FT. Ago r REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT y,f ` 0.� "t L 4C Fkrr Z p�lcryl�—� FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT /�, nn pp /y'�� �� � Q SYSTEM INSTALLED BY: FC aft 1�'L L ahlol AUTHORIZATION NO,�t -1) OPERATION PERMIT BY: DATE: /1010 **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES RIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. Permir,teeis'��,� DAVIE COUNTY HEALTH DEPARTMENT ' `� Name: ?- L�, l` i %..t tCa�+� Environmental Health Section PROPERTY INFORMATION P.O. Box 848 D Directions to property: Mocksville, NC 27028 Subdivision Name: `JPhone #: 336-751-8760 Section: Lot: ( ;1 4 AUTHORIZATION FOR 1 i\(~ 3' _i': t (ct(,W L 1,N t WASTEWATER Tax Office PIN:# - - SYSTEM CONSTRUCTION 1607 1_ „ AUTHORIZATION NO: z< ' ' A Road Name: ° + i J Zip: **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This FonrdAuthorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ,. ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION j;� IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HI1ALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS 3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY Gt t DESIGN WASTEWATER FLOW (GPD) 3f L NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE6LSR"A�. PUMP TANK" GAL. TRENCH WIDTH ` C- ROCK DEPTH L� LINEAR FT. Ano, REQUIRED SITE MODIFICATIONS/CONDITIONS: OPERATION PERMIT� ^ • „ Q SYSTEM INSTALLED BY: `� 'U�, ,(f �_ low Sod � AUTHORIZATION NO - OPERATION PERMIT BY:"-OJDATE: ( 1�?oto **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES RIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 I 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. DCHD 01102 (Revised) PemiittttWs,rz-r f `DAVIE COUNTY HEALTH DEPARTMENT Name:it Environmental Health Section PROPERTY INFORMATION {; C P.O. Box 848 -Directions to property: `i t 0 `(� h1ocksville, NC 27028 Subdivision Name: s P4 ne #: 336-751-8760 Section: Lot: AUTHORIZATION FOR {-i WASTEWATER (ft'L ! l . " 1 Tax Office PIN:# - - _ SYSTEM CONSTRUCTION AUTHORIZATION NO: A Road Nam�ee: P ' ' , < Zip: ,. **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) 1 ti ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS _3 # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFI' y� # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY 'G' d (i DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE - is Vw 1. PUMP TANK- GAL. TRENCH WIDTH ROCK DEPTH ( LINEAR Fr. An0 ' REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUTJ Ci { S � c f, r,-. �t� ,K , s X11 �Cu r� �i C L-Iild s 1 ," iI11 �i__} 11 FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. OPERATION PERMIT CC SYSTEM INSTALLED BY:C NSE j I AUTHORIZATION NO ?� OPERATION PERMIT BY: DATE: 10l r� l i I_ i "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DES RIBED ABOVE 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. ..DCHD 02/02 (Revised) o09 be q unty Health Department n mental Health Section P.O. Box 848 A '1 10 Hospital Street QU 1 ASG �. urier # : 09-40-06 o,ocksville, NC 27028 Plione: (336) - 753 - 6 Gj''� Fax: (336) - 753-1680 ITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: i % �• ��ZfJ"%/i9 Phone Number(Home) Mailing Address:j� %� - (Work) J�&WIle /I/& 220 T Mled Directions To Site: 15Y ! 0 5A; A/ �G1 • 41! Z/V l� C% ENU -IU&A) /I/I XiAIA N </-v_ Dal 0 f&4 ✓W.0-11/iA-7D': t/ Zx,Vg Property Address: 6 Please Fill In The Following Information About The EXISTING Facility: 7 Name System Installed Under:! �l % ALJ%%t/N�/� Type Of Facility: Date System Installed (Month/Date/Year): ZTlql Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yeo If Yes, For How Long? (6-nox) ek S !G Any Known Problems? YesOlfYe//s, Explain: Please Fill In The Following Information About The NEW Facility: 22 Type Of Facility: &05& /M Number Of Bedrooms: V Number of People Pool Size: ge Si Other: ry bp - n(Requested By: Date Requested: �I -0 &Appr:ov: Disapproved Comments: "t-cwwv"(f l.w- For Environmental Health Office Use Only Environmental Health Specialist 10 Date:S/;?3%2(9j0 *The signing of this form by the Enviromnental 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: Cash r Check) Money Order # Paid By:_ Account # Amount:$_- /W' 00 Date: X-1 Received By: 6 ff y Invoice #: "Nip AUI:FOnZATION NQ: 1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee's P.O. Box 848 Name:, Mocksville, NC 27028 Subdivision Name: Phone #: 704-634-8760 Directions to property: <c� L LI MILt." 4t-- Section: Lot: /* P� � AUTHORIZATION FOR rT (� -T t)(2 d ( 1' C c(� pn{ (;-/ WASTEWATER Tax Office PIN:# f SYSTEM �C/ON�S]/T]RU/ /CTION %Jj� 'rd f Q r1 (;k,�iw % IC /Road Name: im i L t_ "-I Zip: c **NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Permits. This Form/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Permits. (In compliance with Article 11,6f G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) f hi i' r �.% ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION C��' IS VALID FOR A PERIOD OF FIVE YEARS. if&v oh NTAL L --Th SPFdALIST DATE ISSUED 1. , 4 4� DAVIE COL NTY HEALTH DEPARTMENT ' M IMPROVEMENT AND OPERATION PERMITS Ferri ittee's Name: Directions to property: ff - IMPROVEMENT 9 .. _i. U C,^' i 1�� t: a,� "ta �,� PERMIT t/ i i • (•'i �--t r f 1 C LR !-Y i �.. GAi z-, J �,� lam' ! M1,111 PROPERTY INFORMATION Subdivision Name: _ Section: Lot: Tax Office PIN:# 1: 1i Lt .Road Name: r � Zip:: **NOTE** This Improvement Permit DOES NOT authorize the construction or installation 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) ***NOTICE*** TI -IIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER gENTAL HEALTH SPECIALIST DATE ISSbED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE M 1-1 # BEDROOMS Z # BATHS r # OCCUPANTS -7— GARBAGE DISPOSAL: Yes or4g) COMMERCIAL SPECIFICATION: FACILITY TYPPE� # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIA_ ?✓�3- • TYP WATER SUPPLY l t� DESIGN WASTEWATER FLOW (GPD) NEW SITE —•"` REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE (22�� GAL. PUMP TANK GAL. TRENCH WIDTH :5L' I I ROCK DEPTH —� LINEAR FT. 7 -co OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: l t, 5 ALL_ 1_I /-J e_c, © A G��rJ T uy IMPROVEMENT PERMIT LAYOUT IOD k 3Lo ac /Z rh uJ 5 � D1ILLIaCo a -j) "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 THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY: � 1,&NV- -DATE 311-7 urjEr> cvt-_rnJ AT 80X >L 110 E 4tj '1 N:�-wl � ST F2� � AUTHORIZATION NO. OPERATION PERMIT BY: DATE: "THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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. DCHD 05/96 (Revised) y, t IF APPLICATION VOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie, County Health Departments fes►' t Environmental Health Section l5 fi� P.O. Box 848 h� S: Mocksville, NC 27028 (704) 634-8760 ** RTANT**** THIS APPLICATION CANNOT BE PROCESSED SS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed Contact Person Mailing Address Home Phone City/State/Zip Business Phone 2. Name on Permit/ATC if Different than Above X46/� Mailing Address 3. Application For: [WSite Evaluation City/State/Zip 14KM"P-rovement Permit & ATC Both 4. System to Serve: [ ] House [,.fMobile Home [ J Business [ ] Industry [ ] Other 5. If Residence: # People� # Bedrooms .Z- # Bathrooms M [-TDishwasher [ ] Garbage Disposal {Washing Machine [ ] Basement/Plumbing [ ] Basement/No Plumbing 6. If Business/Other: Specify # Showers # Urinals # Water Coolers - # People #Sinks # Commodes If Foodservice: # Seats Estimated Water Usage (gallons per day) 7. Type of water supply: Dd County/City [ ] Well [ ] Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes [A+Ko_ If yes, what type? EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT ***XIC.F.LA'W OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: WRITE DIRECTIONS (from Mocksville) TO PROPERTY - Tax Office PIN: t# 575i - asd 22 1•'$ 7 9 Y'^ -,l bn,� Property Address: Road Dame i Yi f�� t L'-_ FQ city/zip iYl oC'K L? 0 2Y ; (w•!1 lrw,�►X- w11Mit- Y)1 • w J If in Subdivision provide information, as follows: Name: Section: Lot #: 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 Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by DATE—1 1- 12 , '11 Revised DCHD (06-96) to conduct all testino procedures as necessary to determine the site suitability. THIS AREA MAY 13E USED FOR DRAtVINC YOUR SITE PLAN: DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME to l t L 14.E ✓ w..� -L- DATE EVALUATED 116b b PROPOSED FACILITY PROPERTY SIZE Z'z Ac Q.R5 SUBDIVISION ROAD NAME�� N� QO Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit Public Cut FACTORS 1 2 3 4 5 6 7 Landscape position I_ Sloe % 5 7 HORIZON I DEPTH O - 7-1 - 10 Texture groupG G Consistence ; 5 Structure 5G k Mineralogy HORIZON II DEPTH Z - - Texture group Consistence F• S Structure 5 k Mineralogy t: HORIZON III DEPTH _Zq - Texture group G F Consistence Structure k - Mineralogy HORIZON IV DEPTH + Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION S $ LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: 8 - LONG -TERM -LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) /'/ Landscane Position EVALUATION BY: _ c -F OTHER(S) PRESENT: W 1 W 4A4 5620✓%'j1ek"S 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 ■■ 2 L.01 m (V l v (9.41Ac) /c .� i4,3ggC 6 ��,�a6 ?52• 2 r m' v 17.04Ac 25 8.41 Ac a F� ti --I 9— o D 8 2 7.5 m1 co 627200 ,h 22.26Ac ro' w (61.50Ac)6.2 8Ac ti pt 258 5 a Q U 02 N v \ 8 728A,-ro or o ��_.._.._..._� .. _ 7 a� 20 4 is � ,ry _1701OD �i 10.4 7Ac v 990 _ 18 17 i i .' 215.40 Ac 10Ac SEE 01 Mqp H_6-7 20 20 00 �4c ;�v,� 10 rn 20ON �. 5 800 ro b Y h 8 268 54c, �0 470 �e d 468 71fi n 1� .� t� 6��.