179 Persimmon Grove Ln4iEALTH DEPARTMENT RELEASE
a Y��
Davie County Health Department
t 210 Hospital Street ,,14A1UM
P.O. Box 848
Mocksville N;;427028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Steven and Cindy Franke
Address: 179 Persimmon Grove Lane
City: Mocksville
State/Zip: NC 27028
Phone #: (717) 658-3211
For Office Use Only
*CDP File Number 157991 - 1
County ID Number:
valuated For: HDR/WWC
PERMIT VAUD 0 g/ 1 0/ a 0 1 9
UNTIL:
�roperty Owner: Steven and Cindy Franke
Address: 179 Persimmon Grove Lane
City: Mocksville
State0p: NC 27028
111�hone #: (717) 658-3211
i Property Location & Site Information
Address 179 Persimmon Grove Rd Subdivision:
Road # Mocksville NC 27028
Township:
Directions
Hwy 64 W. left on Greenhill Rd. Persimmon Grove on Left
'Structure: SINGLE FAMILY
# of Bedrooms: 3
'Water Supply: NIA
Basement: R Yes ❑ No
'Proposed Improvement:
Garage with 3 bays
# of People:
Phase: Lot:
Type of Business:
Total sq. Footage: No. Of Employees:
2
7;
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps. Signature: *Date:
'Issued By: 2140 -Nations, Robert *Date of Issue: 0 9/ 1 0/.2 0 1 4
Authorized State Agent:
**Site Plan/Drawing attached.**
O Hand Drawing Olmport Drawing
0%
Davie County Health Department
Environmental Health Section:,.rt.�
P.O. Box 848
~ F
4 210 Hospital Street rl,
peat" Courier # : 09-40-06
a Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Name: Veyen 1,t1. cm (ndq Loge Ff-"ke- Phone Number (717)&St3-3aI I (G gdu (cg(Home)
Mailing Address: 17q Azfzj l M QV) Grove_ Lanp_ (717) (o 5S- 3;7,08 (& ye -(Work)
MOC sV� 11 e
MC J -702B 5510 Email Address: c l frnh kp (@ yad f y_1 n e+
Detailed Directions To Site: Greer 1, i ll Roo -d -From COunlu 14ame- Ra t'd q,1d11 op Green h'd1 2—c d _
pa55 Uri-irl_-Yi ('.1 A on IeN- AonroY_ 50 feet socti, -burn 166 on -L PerZawMOn Grove- L.nL 2L( travel
j n Ian e, beat- Ieff 4p sub-, e& sift
Property Address: E
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: -RQ 1l1 Sn11 Type Of Facility: Re51dP -- 3 beJrWrA
o V>7e
Date System Installed (Month/Date/Year): rlA0 Number Of Bedrooms: _,�Number Of People:.2.
Is The Facility Currently Vacant? Yes 9 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 Facility: Gcyme, to lk 3 bows Number Of Bedrooms: b Number of People 0
Pool Size: vdoL Garage Size: 30" x 36 Other:
Requested By: (i, d'w %je � Date Requested: 0 10 312D1 O
(Signa e)
For Environmental Health Office Use Only
Approved Disapproved
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 or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash (check) Money Order #
Amount:$
Paid By: Received By: f
Account #• Invoice #: - o�, /c!
/5 '?L90
Date: `/'
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Davie County, NC Tax Parcel Report Monday, July 8, 2013
..7-77
-� 5.521
r X123
t ~ (
10.360A
J 179 11
(4.071}-' '
1
z4.
1.44zA
SCENIC OR -••.—...
231
\. 1221
-- - ---------------
�,�oG�c2o2
Parcel Number:
J30000002305
NCP1N Number:
5728600056
Account Number:
82525262
Listed Owner 1:
HENDRIX DEBORAH J
Mailing Address 1:
7528 MAIDWOOD COURT
City:
CLEMMONS
State:
NC
Zlp Code:
27012-9098
Legal Description:
10.360 AC OFF GREENHILL
Assessed Acreage:
10.28
Deed Date:
10/2005
Deed Book/Page:
006300869
Plat Book:
0008
Plat Page:
249
Building Value:
225350.00
Outbuilding & Extra
0.00
Freatures Value:
Land Value:
56030.00
Total Market Value:
281380.00
Total Assessed Value:
281380.00
WARNING: THIS IS NOTA SURVEY
Parcel Information
Township:
Mocksville
Municipality:
Census Tract:
37059-801
Voting Precinct:
SOUTH MOCKSVILLE
Planning Jurisdiction:
Davie County
Zoning Class:
DAVIE COUNTY R -A
Zoning Overlay:
Voluntary Ag. District:
No
Fire Response District:
MOCKSVILLE
Elementary School Zone:
MOCKSVILLE
Middle School Zone:
SOUTH DAVIE
Soil Types:
ChA,GnB2,EnB,MsC,MsD
Flood Zone:
X
Watershed Overlay:
WS -IV -P
v �vre 1 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, NC ' implied 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
f I causes of action due to or arising out of the use or inability to use the GIS data provided by this website.
06/27/201, 07:53 3367531680 DCEH PAGE 01/01
•� DAVIE COUNTY HEALTH DEPARTMENT Q t
t l Environmental Health Section +
P. 0. Box 848/210 hospital Street .�
Mocksville, NC 27028
(336)751-8760
Account #: 990003720 Tax PIN/EH #: 572-59-7580 DH
Billed To: Deborah Hendrix Subdivision Info:
Reference Name:
I_ocatioh/Address; 1'7'x! P6Q3j,41,R0A ik1) ✓E'6)
Proposed Facility Residence Property Size: 10.36 acres
ATC Number: 4192
AUTFTORIZATTON FOR WASTEWATER SYSTEM CONSTRUCTION
"NO I F." This Authorization for Wastewater System Construction WST BE JSSUED 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 WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS.
Environmental Health Specialist's Signature: Date: t�
CERTIFICATE OF COMPLETION
**NOTE— The issuance of this Certificate of Completion shall indicate the system described on Jmprovement/Operation Permit
has been installed in compliance with Article 1 of G.S. ter 130A, Section .1900 "Sewage Treatment and
Disposal Systems," but shall i O WAY be take s a - a tee that the system will function satisfactorily for any
given period of time.
�ja
�Ml
Septic System 1nstulled By:�e-1
Environmental Health Specialist's Signature : /'moi'/~ Date:f
DC14D 05/99 (Revised)