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174 Rose Arbor Ln (2) . , . : .. .• � _ _ .. . , , �,l Davie County Health Departme�gtQ�►��, � � ��s� • �F��' vironmental Health Sectior� � �° r4 P.O. Box 848 D � ' ' t� ` � '� EC 8 2012 ' C� �-�• 2 2 1 0 H o s p i t a l S t r e e t e Y `�''� � � �tJ � Yt , Courier# : 09-40-06 Mocksville, NC 27028 `� Phone:(336)-753-6780 , Fax:(336)-751-8786 ON-SITE WASTEWATER CER,TIFICATION FOR;DWELLING (Check One) Replacement ►�Remodeling Reconnection Name:_�'��C'Q�� Phone Number 336• 9`� 0 •��`�_,(1-lorne) Mailing Address: 3�6_��'['nW� �� d �� •d�� (Work) �C�SU�L�. �C �"7 d 7.0 Email - cV��CD'�1n, . Detailed Directions To Site:�W T {,� . " L�� ,, ��'��.�. ��/f}� �2• r�A L L�-� , L��`�" a�, �� R. L� .� .. •�a1�d v�J tZ��--�'�`� l . Properry Address:_f��_�C ��,�,�� 1/ •� � c �.� -t�— Please Fill In The Following Information About The EXISTING Facility: Name System Installed Undcr:�7�y�� • T��pe Of Facility:SI�L 6� �L� rJ�,�j1�G Date System Installed(Month/Date/Year): Z��j Number Of Bedrooms:_3 Number Of People: � � Is The Facility Currently Vacant7 Yes � If Yes,For How[.on�? Any Known ProblemsT Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility:�� Number Of Bedrooms: � Number of People Z �l�r►i� Requested By: �� -�� Date Requested: �Z• Lo ' �Z (Signaturc) . For Environmental Health Office Use Only pproved Disapproved Comments:_�(�l�Q l5 ��Y' b�^�-��-E�C��CQ� � _ _�11.1 abQS �O t1�e_x�nC,,xlSl�ri_L2I" � � 5.___�.�S�t.r�---�Q,1� i S r�1 p�Of� 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 # �Z�,_Amount:$ d�.(� Date:_`� �� ____ � . Paid By: �.1�'�(�� Received By:�_�_(>R- Account#: �� Invoice#: ��7� • . . CD��lI��l� � , � • Appraisal Card , � , Page 1 of 1 . , � � Jo�v� laf �- � E�� rE ��- d��u� DAVIE COUNTY NC 1 4 2013 2:42:08 PM WENS BARRY M OWENS BARBARA T . Retum/Appeal No[es: I6-000.00-075-12 174 ROSE ARBOR W UNIQ ID 16952 2517272 � � . D266-P12 ID N0:5758636709 - � � COUNTY TAX(100),FIRE TAX(100) G1RD NO.1 of 1 � . eval Year.2009 Tax Year.2013 22.500 AC CORNARER RD � 22.070 AC ' SRC=Inspec[fon : ralsed b 19 on 09/04/2008 07001 SHADY GROVE TW-07 C- E%-AT- LAST ACTION 20100922 C - CONSTRUCTION DETAIL MARKET VALUE DEPRECIAttON CORRELATION OF VALUE - oundation-3 Eff. BASE StanEard 0.2000 �'' T . ontlnuous Footin 5.0 US MO Area UA RATE RCN EYB AYB � REDENGE TO . MARKET � ub Floor Sys[em-4 � � 1 ood 8.0 Ol Ol 3 292 106 73.14 243028 198 198 %GOOD 80.0 DEVR.BUIIDING VALUE-CARD 194 42 �,' uterior Walls-30 TYPE:Single Famlly Residentlal Single Famlly Residen[lal EPR.OB/XF VALUE-CARD 37,84 � . iuminum�n I Sidin 29.0 , . MARKET LAND VALUE-CARD 143,68 . oofing SWcture-03 . STORIES:3-2.0 5[ories � OTAL MARKET VAWE-CARD 375,94 r . able 8.0 oofing Cover-03 � � � � s halt or Com sltlon Shin le 3.0 • , OTAL APPRAISED VAW E-CARD � 375,94 � , nterlor Wall Cons[ruUlon-5 . � OTAL APPRAISED VAW E-VARCEL .375,94 . wall/Sheetrock 20A . . ' nterlor Floor Cover-08 � � � heet Vin 1/laminate � 0.0 � � OTAL PRFSENT USE VALUE-PARCEL OTAL VAWE DEFERRED-PARCEL � nterior Floor Cover-14 � et 6.0 � OTAL TAXABLE VALUE-PARCEL 375,94 � 1-18-I eattng Fuel-03 � . 2 2 pRIOR as 1.0 +9-+11� + , eating Type-04 . I U B M I � � � BUILDING VALUE 229,94 . I I BXF VALUE � 0 orced AIr-Ducted 4.0 I I ND VALUE 87,40 � ir Conditioning Type-03 I I RESENT USE VALUE � � en[ral 4.0 4 4 EFERRED VALUE . � � drooms/Bathrooms/Haif-Bathrooms 0 � O OTAL VALUE 317 34 � � ' /2/1 13.00 I = � � edrooms � I I � AS-1FU5-2LL-0 I I y +----40----+ � athrooms � - � r AS-OFUS-2LL-0 +-18-+ � PERMIT alf-Bathrooms 1 W D D 1 � CODE DATE NOTE NUMBER AMOUNT �� BAS-IFUS-OLL-O 4 4 . � OTAL POINT VALUE 101.W � +-1 8-+ , '-"+ 1 I ROUT:WTRSHD: � BUILDING AD]USTMENTS p ,1 �' � SALES DATA � � uali 3 AVG 1.000 +i i+ 2 O ha e/Desi 5 FACTOR 5 1.100 1 9-+ + + +----4 0----+ RECORD DATE DEED IN Ai STE N � ize 3 Size 0.950 0 6 A 5 I I F U S I „', +-2 2--+ I 2 2 BOOK PAGE M R TYPE / / PRICE r..� OTAL ADJUSTMENT FACTOR 1.05 I F G D I I 0 � O 0380 322 7 001 WD I 27300 OTAL QUALITY INOE% 10 2 Z 4 +----4 0----+ � 2 2 O I I I .. +-22--+ I +----4 0- ---+ HEATED AREA 2,638 � � . � . 7FOP 7 ' . � � +----40----+ NOTES � � � FOR SALE � � � . ROM NOLT HAYWOOD � ' � � OLD 1 AC 2000-75.13 ' ITH DW 82K . SUBAREA UNIT ORIG% ANN DEP % OB/XF DEPR. . � TYVE GSAREA No RPLCS ODEDESCRIVTIONLTH HUNIT PRICE COND BLDGffL BAYBEVB RATE �OV� COND VAWE � AS • 1 63 10 134431 8 OUViNYL 44 20 880 37.40 0 _ . L 199 199 SS - 15 493 � GD 48 04 1594 55 AZEBO 30 1' 36U 16.00 300 _ l 198 1989 53 40 23 � OP 28 03 716 ES ENCE METAL 0 0 300 15.80 300 _ L 199 1999 .54 60 2844 � US � 80 09 52661 Z ARAGE � 4 2 1,15 15.0 _ L 00 00 5 88 15206 BM 1 63 02 2691 30 ON PAVING 8 2 1,92 4.0 _ L 00 005 SS 8 6144 � . 10 ON DAVING 12 1 2 00 4.0 L 200 005 S 8 640 DD 25 02 365 OTAL OB/XFVALUE 37935 IREPLACE 3-1 5[ory Z�ZS . � Sin le . UBAREA 5.49 43.02 � . ' . OTALS BUILDING DSMEN520N5 BAS=WINI2WDD=N14W18514E18S W18512W1N2W1152W9510FGD=W22522E2ZN22f 530FOP=57E40N7W40$E40N40S�R=E15FU5=E40520W40N20 �� W15N40UBM=N40WIN12W18512WIN2W1152W9540E40$540$. � � NDINFORMATION ' � � � - � . IGHEST THER AD]USTMENTS LAND TOTAL ND BEST USE LOCAL FRON DEPTH/ LND COND ND NOTES ROA UNIT LAND UNT TOTAL AD)USTED LAND LAND . � � SE CODE ZONING TAGE DEPTH SI2E MOD FACT RF AC LC TO OT TYPE PRICE UNITS TYP AD)ST UNIT VRICE VALUE NOTES � , RURAL AC 0120 80 0 I.0000 4 0.7000 30+20+00-20-20 PW 9 300.0 22.07 AC 0.70 6 510.0 14367 HAPE - � OTAL MARKET LAND DATA � � 22.07 143,68 OTAL VRESENT USE DATA � ♦ ► http://maps.co.davie.nc.us/ITSNetlAppraisalCard.aspx?parce1=I60000007512 1/4/2013 . � _ .... . : . ... . . . . . . -BK3.8UPG32�4� .. EX�PI'"A" � BBGINNIIVG at a railrond spi7ce in the ceoier of SR 1605 right=of-way pocaUY Imovw as the ; "Cornatzer Road'�,�e Northeast comer of James E.Handxix(Aeed Hook 125,Page 846)and nmamg theuca with Hendrix line Soud�80°26'20"West paumg through aa iron pipo in the ' Westem righi-0f-way margin of SR 1605 at 30 fioot for a tatal distanca of 638.75 fat to aa iroa" • Pipa. Handtix comor; theace caatinuing with Hmdrix lino Souih 44° 44' 20" West passing . thtough an icnn pipe in the Notthem bank of Dutchman Crak at 421.19�oet for a tatal distauce of 456.89 feet to a poiat im U�e cmtor of Dutd�»sma Croek;thmce up and with the ceater of said _ ctedc as it suos in a Westem.diroctiaa the.following caurses and distaaces:Notth 81°45'47" Weat 183.97 fed,North 73°38'48"Wat 198.99 fae,t,Noith 88°35'38"West 223.65 fed�Srnrth . . 80° 45' 07"West 120.74 feot theaco leuvu�g the said Du2d�man Crxk and mm�ing with the ' canter line of an mtarseciing branch as the same moanders in a NotThem dicedian the following . c.ourses aad distanca: North Sl°13'28"West 167.67 Seet Nath 20°24'S2"East 261.25 feot, North 04°45'28"Wett 178.0 fat;thenoe leaviog said brauch Nath 72°50'22"East 1240.19 feet to an isnn;thmoe Swth 69 degt�ees 39 miautes 22 seoards Faat passiag tluougkt an itm pipe ia the western right�frway ma�gin of SR 1605 at 423.55 foot f�a total distaaee of A54.39 to a aail in the omter of SR 1605 right�oflvay, thmce with the teater of said right-of�wry the follawing courses and distaaces: South Ol°54'00"F,ast 110.77 fxt.South 09°48'24"E?ast 100.09 feet,So�.616°14'48"Fast 100.07 feet,Saarti�21°34'36"East 99.94 fcei to the POIIVT . AND PLACE QF BEGINNING, amainrog 24.5 aeres,mon or less.as surveyed by Fraacas GteaA0.�►Pril Z3, 1987.and bei�g a pottiaa of those lands descn'bad by deed tscorded in Dood • Book 75�Page 807,Davie Ca�aty Registry. Snbjed to a 30-foot wide acass and.utilrtias aasan�eat leadmg fraa Comatzer Road, the , aaterl"me of�id easc�mt being desctibed as follows: BEGINNIIVG at s gomt,aaid poi�bamg located'm the c�liae of Cama�zor Road and also beiog locatad the follovving two(2)counes ' aad distantas f�sn an,iran in t6a Sotdheast comer of Clota N.Bivms,Dad Book 147,Page 825, Davie Co�mty Regisdy:(1)South 69°38'03"Fast 30.85 feat;and(2)Soirth Oi°54'00"East • ' 20.10 feet;theuce fnom said point of$egmnmg North 75°43'22"West 213.13 fijet to a pouR; thmce South 12°44'36"West 39.60&et to a point;thence South 09°SO'38"East 78.61 fcet to a poiat;thmce South 09°47'04"Fast 183.86 feat to a poinR. ' . SAVE AND EXCEPT: . . TRACT ONE: � • ' BEGINNING at an iron,said iron beiag located in the Westem rig�t oF way line af Comatmr Road and also being loeated in the Northaast comer of Robert�.Rosa,Dood Book 191,Page 236,Davie Camty Regis�y;thenoe�aan�aid pomc of Begmnm8 alm8 Rose's North line South -80°42'41"West 239.47 fed to an itw;ihwce No�th 09°17' 19"Wast 173.40 fod to aa ixns►; • thmce Nocth 81°04'2y"East 239.19 fat to a point ia the cauted'me of Cocnatzer Road,crossing an iraa at 208.07 feet;thaqce wrth the ccnterlina of Comatzot Rcad Sarth 16°14'48"Fast 74.65 . 'feet to a poinR;thmce caatinumg with me ceaLedina of Cotnatzer Roacf South 21°41' 16"East . �, 100.12 fed to a poiat;thence South 80°42'41"Wat 30.24 foet to an icm,the poiai and ptaca of Heginna�g,cmtammg 1.000 acros,moro or lass,aad bemg ia aaordance with a survey PaQared . by George ltobeR Stoae,PLS,datod May 31.2000. 'Ihe above-described P�P�Y is a portian of � Tax parcel 75.05,Map I-6,Davie Coimty Tax Maps. . . . . . . .., :r;'k,-11'Ji. . . . . . .1' , .Z-`' ., - ' . .. . . . . �:. � .. 11.;•. . . . . ' . . . ' '�h,. ��' ' , ' . ' + . , ' •''''Ir," _ , ' . .. . . . . •4 . . . y�- •. ♦ � . . ' • � • ' � . BK38�OPG325 �rRncr�rwo: BEGINNING at a poini located ia tho cxatedine of Comatrsr Road,said point also beiag in tha Nostheast comer of the Weudy W. Johnson pcoperty (Sea Iked Book 341, Pago 430, Davie C�tY�B�Y):mm�ing thenco with Johosan South 81°04'2T'Wost 239.17 fe�w an iron , stake,tha Northwesi comer of Ja�hnsoa;tu�mmg theeee ar a new liae with Alicia D.Btink,the two(2)Sollowiag counes aad distances: North 09°17'19"West 183.85 feei W an iran stake and North 81°04'27"East 242.77 to a point located'm the centedine of Comatzer Ruad,mm�iug thmce with canteriiae of Coraatzer Rosd tha three follawing courus aad diatances:South 01° � 54'00"Fast 59.0 feet to a poiat;South 09°48'24"East 100.09 feat to a poirit and South 16°14' 48"Fast 25.42 foet to the point and place of Baginning,containing 1.0 acre and bea�g part of T'ax parco175.05,Map I�as p�esartly shawn ar the Davie County Taz Maps. � • • � . . ' 'p..� �" . . . � . .. . � ' t` . ' ' , . . . . _ � . , .3: 'ar .. ' ��.: . ' . . ' : � � . . . . :�;� ' .. . {�, `1.'_�, ' ;.. . . . . . , �. � .. ' �. . . . . .. . • . . . . . . .� . . .� . . � �j �:. �,,�1� YtY� F.N,.!. 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OPy�� i . � • V ✓� AII daW is provided as Is without warranty or guarentee of any kind either expressed or implied including but not Iimited to the implied ,y ��F; warranties ot merchanWbility or fitness for a particular use.All users of Davie County'a GIS website shati hoid harmless the County of � ��11 N� � Davie,North Carolina,its agents,eonsultants,conVacton or employees from any and all claims or causes of action due to or arising out of P ri nted:N ov 16� 2��G � . the use or inability to use tl�e GIS data provided by this website. � Appraisal Card , Page 1 of 1 . . . . � DAVIE COUNTY NC - � 11 16 2012 4:30:26 PM WENS BARRY M OWENS BARBARAT � Retum/Appeal Notes: I6-000-00-075-12 174 ROSE ARBOR LN � UNIQ[D 16952 2517272 . � � D266-P12 ID N0:5758636709 � � - COUNTY TAX(100),FiRE TAX(100) CARD N0.1 of 1 � � � � Reval Year.2009 Tax Year.Z013 � 22.500 AC CORNATZER RD . 22.070 AC SRC=InspeRion � � � � raised b 19 on 09/04/2008 07001 SHADY GROVE TW-07 G EX-A7- � LAST ACTION 20100922 U � �. CONSTRUCTION DETAIL MARKET VALUE � DEPRECIATTON CORRELAttON OF VALUE . �� , � Foundation-3 StandarA 0.2000 . ,' � on[inuous Footin � SA Eff. BASE . � �� . ub Floor System-4 US MO Area UA RATE RCN EYB AYB REDENCE 70 � �� MARKET � , . . I ood � 8.0 Ol 01 3 292 106 73.14 24302 198 198 %GOOD 80.0 DEPR.BUIIDINCa VALUE-CARD 194 42 . Exterior Walls-SO . TYPE:Single Famity Residentlat ' Singie Family Residential DFPR.OB/XF VAWE-CARD 37,84 _ . IuminumN��I Sidin 29.0 � � MARKET LAND VALUE-CARD 143,68 _ . � RooFlng Structure-03 . STORIES:3-2.0 Stories � . , OTAL MARKET VALUE-CARD 375,94 � . aDle � 8A . . � - � Roofing Cover-03 � , - s hait or Com osition Shin le � 3.0 � � , � OTAI APPRAISED VALUE-CARD 375,94 � . nterior Wall ConstruQion-5 � OTAL APPRAISED VALUE-PARCEL 375,94 � � ali/Shee[rotk 20A . � � nterior Floor Cover-08 . � OTAL PRESENT USE VAWE-PARCEL - . - heet Vin 1/Laminate 0.0 � . OTAL VALUE DEFERRED-PARCEL . nterlor Floor Cover-14 OTAL TA7CABLE VALUE-PARCEL 375,94 � ret � 6.0 1-18-1 � � � � eating Fuel-03 � � � 2 2 VRIOfl � � as 1.0 +9-+1 1+ + . BUILDING VALUE � � 229,94 . eating TyDe-04 I U B M = BXf VAWE . orced Air-Ducted 4.0 I i ND VALUE 87,40 � ir Conditioning Type-03 I = RESENT USE VALUE � . entral 4.0 4 4 EFERREDVALUE� � � Bedrooms/Bathrooms/Haif-Ba[hrooms� 0 0 OTAL VALUE 317 34 � . � /2/1 13.00 = I . � Bedrooms I I � - � i I AS-1FU5-2LL-0 +----40----+ m � athrooms - � AS-OFUS-2LL-0 +-18-+ PERMIT � � � 1 W D D 1 CODE DATE NOTE NUMBER AMOUNT �� alf-Ba[hrooms - AS-1FU5-OLL-O � � 4 4 . o . � OTALPOINTVAWE 101.00 � +-16-+ . '� � . 1 I . ROUT:V✓TRSHD: `� BUILDING AD)USTMENTS O 1 � SALES DAU �c ual( 3 AVG 1.000 � +1 1+ 2 FF. INDICATE `� � � ha e Desi 5 FACTOR 5 1.100 1 9-+ + + ' +----4 0----+ RECORD ATE DEED SALES �� ize 3 Size 0.950 0 B A 5 I I F U S I ,: � � +-2 2--+ I 2 2 BOOK GAGE M R TYPE / / PRICE , N OTAL ADJUSTMENT FACTOR 1.05 I F G D I I 0 � 0 0380 322 7 001 WD I 27300 � OTAL QUALiTY INDEX � 10 2 2 4 +----4 0----i � � 2 2 0 . I I I � . +-22--+ � � I � +----4 0----+ HEATED AREA 2,638 7FOP 7 +----40----+ NOTES FOR SALE � . � FROM HOLT HAYWOOD � � OLD 1 AC 2000-75.11 � ITH DW 92K � SUBAREA UNIT ORIC% ANN DEP % OB/XF DEPR. � � TYPE - GSAREA h RPLCS ODEDESCRIDTIONLTHWTHUNIT PRICE COND BLDG#L BAYBEYB RATE OV COND VAWE . � � � BAS 1 83 10 134431 8 OOL/VINYL 44 20 880 37.40 0 _ L 199 1992 55 15 493 . � . � FGD 48 04 1594 55 AZEBO 30 1' 360 16.00 300 _ L 198 1989 53 40 230 FOP 28 03 716 ES ENCE METAL 0 0 300 I5.80 300 _ L 199 199 6 2844 . FUS � 80 09 52661 Z ARAGE 4 2 1,15 15.0 _ L 00 00 53 88 1520 . BM 1 83 02 2691 10 ON PAVING 8 2 1,92 4.0 L 00 00 SS 60 6144 � � � 10 ON PAViNG 12 1 2 00 4.0 L 00 00 SS 6 640 DD 25 02 365 OTAL OB/XF VALUE � 37835 � FIREPLACE 3-1 Story z�Zs � . Sin le UBAREA 5,49 43,02 . � � OTAlS BUILDING DIMENSIONS BA5=W1N12WDD=N14W18514E18;W38512WiN2W1152W9510FGD=W22522E22N22j 530FOP=57E40N7W40$E40N40$PTR=E15FU5=E40520W40N20 . . W15N40UBM=N40WIN12W18512W1N2W1152W9540E40 540 . - NDINFORMATION - IGHEST THERADJUSTMENTS LAND TOTAL � ND BEST USE LOWL FRON DEPTH/ LND COND ND NOTES ROA UNIT LAND UNT TOTAL AD)USTED LAND LAND SE CODE ZONING TAGE EPT SI2E MOD FACT RF AC LC TO OT TYVE VRICE UNITS TYP AD75T UNIT PRICE VALUE NOTES URALAC 0120 80 0 1.0000 4 0.7000 10+20+00-20-20 FW 9 300.0 22.07 AC 0.70 6 510.0 14367 HAPE � OTAL MARKET LAND DATA 22.07 143,68 . . OTAL VRESENT USE DATA � � � http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parce1=I60000007512 11/16/2012 . :... .._ ., _: ; ; . . . , "•� . . - .. .._ . .. ._ _ -,.. ,. _._ . - a:,,p .. _ . • -- c I Ptrmic�� ► .-_._ ,f ', ; DAVIE COUNTY HEALTH DEPARTMENT ' '. �� `7�—'J�� Cj Name: f�� ' � --� Environmental Health Section PROPERTY INFORMATION � ,. � • � P.O.Box 848' f, j l =Directions to property: ��`� (�%%S"ti .+�✓� ��+�,��'%'�qocksville;NC 27028 Subdivision Name: �� .. , ., ` Phone#:336-751-8760 o-:.��f;�/ ,r%.. Gl�/ (', Section: Lot: ,� �r, - -ti AUTHORIZATION FOR . ('�-��'� �r, �� l,,/' ,j • ,�', ' . WASTEWATER , - - � Tax Office PIN:# ` SYSTF.M CONSTRUCTION AUTHORIZATION NO: �� ose, �R�ia,Q �Zip: �� A Road Name: **NOT'E**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Counry Environmental Health Section prior to issuance of any Building Permits.This Form/Authorization Numher should be presenfed to the Davie County Building Inspections Office when applying for$uilding Perrnits. (ln compliance with Article.l 1 of G.S.C�pter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) f , '�../ �rt% �� '- / ***NOTICE***TH1S AUTHORIZATION FOR WASTEWATER CONSTRUCTION �`�%f�`;�1� !''r�`f _.a .�.� �F/�'//� i�� IS VALID FOR A PERIOD OF FIVE YEARS. . ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED. RFSIDENTIAL SPECIFICATION:BUILDING TYPE�`#BEllROOMS�ii BATHS�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILTI'Y TYPE #PEOPLE #PEOPLEISHIFI' #SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY� DESIGN WASTEWATER FLOW(GPD) / �Y NEVJ SITE REPAIR S1TE � ' .. "'� , SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK =GA�. #t'I�t�rt3 WILITH �:\.��OCK DEPTH� LINEAR FT.��/ l , � L""'i '� OTHER " l7 �/�,l�J� �� REQUIRED SITE MODIFICATIONS/CONDITIONS: ' IMPROVEMENT PERMIT LAYOUT �� ,1 �� 6 � i. . ��X��y **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 (336)751-8760. . : OPERATION PERMIT � y/ - . SYSTEM INSTALLED BY: � � � �/ ' w�1;� � � : f G^�✓ ' AUTHORIZATION NO�OPERATION PERMIT BY: � � DATE: �� "�6 !J� ' '*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 WII.L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. � ., DCHD 02/02(Revise� � `,�� U � •. �,. �S� �� , . ` , �-� � �" ��S � ' t :. , . : .: : . . . — _ _ ..�... . ..,- __ :< t`n .,, !� � . 1 , ' �: . ', :�. ,.: , „ . ., �:.:r .... .-= , - � , � ;� ,,,� r!� .: ,. , �, f�-��`�� ° ' DAVIE�COUNTYHEALTH,DEPARTMENT . �� `�`-� �—�� ' ,�'.. .. t � �une: +�°`� r'ti' �� y�:- -� �. Environmental Health Section PROPERTY INFORMATION - ;' r �_r-� ' ,. P.O.Box 848 `' �Duelliflins to ro ert : ��"�.a`' ��; F . �'.:.�', ^ `��I P_ P Y . , � Mocksville;NC 27028 , Subdivision Name: , y ' Phone#: 336-751-8760 . �a.. ,. � ; ¢ + ,•�"��,�� , � �,a ;,� : :� Section: 'r ' Lot: i • , �J � . . AUTHORIZATION FOR �� t ' . �, ;=` . ' WASTEWATER Tax Of�Ge PIN:#- _ _ � SYSTEM CONSTRUCTION ,�, s � AUTHORIZATION NO: - ��,�'�i A � Road Name: a S� �Rbo� CNZip: ��a� . **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 PermiGs. (ln compliance with Artide 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) ; ' ,� '' -' ;��+''~ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION '/� ��{ 'i��1��''ifT�� ''- :.'�� IS VALID FOR A PERIOD OF FTVE YEARS.' , : ENVIRONMENTAL HEALTH SPECfALIST DATE ISSUED _ RESIDENTIAL SPECIFICATION:BUILDING TYPE �� #BEllROOMS�#BATHS�#OCCUPANTS�GARBAGE DISPOSAL:Yes or No COMMERCIAL SPECIFICATION: FACILI7'Y TYPE #PEOPLE #PEOPLFJSHIFT #SEATS INDUSTRIAL WASTE:Yes or No .�f,r,/� LOT SIZE TYPE.�VATER SUPPLY �' DESIGN WASTEWATER FLOW(GPD) �` U�NEW SITE REPAIR SITE_ �~' ; " ' � , {E Y , t: '�-� ROCK DEPTH�LINEAR Ff."�� SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL TRENCH WIDTH f"� :.F _ OTHER � U< <�,-1 I;-', J. f' �f��l ��7`' � REQUIRED SITE MODIFICATIONS/CONDITIONS: .-,.......: IMPROVEMENT PERMIT LAYOUT -' . ' ' � ; Ul�."/A� t . , .. . . . . . . . � . � . . . / I � . . � � � . . .� �. �. � ��Y � � .�. . �� . � . . . - � . . . ♦ . ,� . '. ; ,. :l �p�,,,�� -�°'` �� ,, . � �6 � � � , � �;� i� ,k ��X�� . , +*CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 830-9:30 A.M.OR 1:00-1:30 P.M.ON THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760:""` OPERATION PERMIT �}) � . SYSTEM INSTALLED BY:�r Gt ll '�l i/ �� 1 Y/ �`�� 1 �. _ � , � ;, , � _, �� . _ � . � �. ..� , , � . : . : . � �� / , � "AUTHORIZATION NO v -.S�� OPERATION PERMIT BY: �, DATE: I� / � � , �� *'THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE I 1 OF G.S.CHAP'TER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPO�SAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WILi.FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. `� � t �D��,.�� /� �D � ��``��''��//��yryr•• �� /f�'''� � � _,_,�� ,.5"�� , � �� i./ �� ' . . . . . ��Y 4 �� .. � . . •�' , ` ��. ., .: _ , ' , •� �' � � �.�� , , , . , , • . . _. . .s.... . _ . 4. ' ( i DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION � • f�fDD / APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) �`�`�r`�`��' / NAME � � PHONE NUMBER ' �C� E�1� ADDRESS � 7 , �� e SUBDIVISION NAME � � ��"/� �� - LOT # DIRECTIONS TO SITE ��/�� G�d`��-/�� . • e.. �/�6��C`�t'�-�- .,�-- o .l i - - . __ DATE SYSTEM INSTALLED �� AME SYSTEM INSTALLED UNDER °� TYPE FACILITY ,1� NUMBER BEDROOMS NUMBER PEOPLE SERVED ' TYPE WATER SUPPLY SPECIFY PROBLEM OCCURRING � ' �J J`h. dZ� DATE REC�UESTED INFORMATION TAKEN BY This is to certity that the informatlon provided is cortect to the best of my knowledge,and at I underetan r sponsible for all charpes incuned irom this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93 ' . .. . ' � •r ' . 4 ` DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87C►0 Account #: 989900636 Tax PIN/EH#: 5758-53-9642 � Billed To: Alicia Bean Subdivision Info: Reference Name: Alicia Bean Location/Address: Rose Arbor Lane-27028 Proposed Facility: Residence Property Size: 24.5 Acres ATC Number: 2090 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION **NOTE** This Authorization for Wastewater System Construction MLTST 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 WASTEWA�_ STRUCTION IS VALID FOR A PERIOD OF FIVE YEARS. Environmental Health Specialist's Signature: . � Date: �� CERTIFICATE OF COMPLETION **NOTE**The issuance of this Certificate of Completion shall indicate the system described on ImprovemendOperation Permit has been instailed 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 Iguarantee that the system will function satisfactorily for any � given period of time. �� ! /tz�--�� , �' �� oa �mr !� a$ �o� --� °J� Septic System Installed By: �OF��- 8/C%r Environmental Health Specialist's Signature: ate: , ��p'�/7 DCHD OS/99(Revised) C •, . , DAVIE COUNTY HEALTH DEPARTMENT � / ��/2�� - � • ' Environmental Health Section L� P.O.Boa 848/210 Hospital Street Mocksville,NC 27028 (336)751-87G0 IMPROVEMENT/OPERATION PERMI� Account #: 989900636 Tax PIN/EH#: 5758-53-9642 Biiled To: Alicia Bean Subdivision Info: Reference Name: Alicia Bean Location/Address: Rose Arbor Lane-27028 Proposed Facility: Residence Property Size: 24.5 Acres ATC Number. 2090 **NOTE** This[mprovemendOperation Permit DOES NOT authorize the construction ofa septic tank system or any wastewater system. An ALJTHORIZATION 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 PERMTT IS SUBJECT TO REVOCATION IF SITE PLANS OR Tf�INTENDED USE CHANGE. YOUR WASTEWATER SYSTEM CONTRACTOR MUST SEE THIS PERNIIT BEFORE INSTALLING SYSTEM. Residentiai Specification: Building Type . #People� #Bedrooms -� #Baths�_ Dishwasher: � Garbage Disposal: � Washing Machine:f� Basement w/Plumbing: � Basement/No Plumbing: � Commercial Specification: Facility Type #People #PeoplelShift #Seats Industrial Waste: ❑ Lot Size r Type Water Supply Design Wastewater Flow(GPD�� Site: New� Repair❑ � i. t� System Specifications: Tank Size�GAL. Pump ank ' GAL. Trench Width� Rock Depth� Linear Ft�� Other: �1 Required Site Modifications/Conditions: � r iMPROVEMENT/OPERATION PERMIT LAYOUT- APPROVED EFFLUENT FILTER RISER(S) IF 6"BELOW FINISHED GRADE. ****NOTICE: Contact a representative ofthe Davie County Health Department for final inspection ofthis system between 8:30 a.m.to 9:30 a.m.or 1:00 p.m.to 1:30 p.m.on the day�f installation. Telephone#is(336)7.51-8760.**** � _ Im°2 I ,D� ioo� �� / / � , � � , �� `-y"q�< �� `!°n�S ' ' /�' i �D_L'e �� 9 � �� sr I /vL�.,.!o' � T o � ��° s �� _ �� ,� �a � !� � � �rn,� e.,��; ��"� � � ' , �/ - Environmental Health Specialist s Signature: �---'� Date:__ Co �9 DCHD OS/99(Revised) Environmenta/Hea/tfiSedion �� v � � . . • �, � •- P.O. Box 848/210 Hoapital Street ' � . Mockavilie, NC 27028 � • �'�Y�� Z �� . " (336)751-8760 ***II�ORTANT*** THI$ APPLICATION CANNOT BE PROCESSED UNLESS THE REQUIRED INFORt�TION IS PROVIDED. Refer to the INFORt9�TION BULLETSN for inatructions. i. N�. to b. siii.a lq L I L 1 �' �7 F.3-C fl IJ , coat�ot �.oa S�A�M E Mailinq llddr�,s 1�'� l2 d S � �-g'��^ LN , som� phoa. ��'�-8��} City/Stat�/ZIP rn o��;s v c c. c,E� /�G o1-�o�--O Busix�u Phosu �(o(p ' �s � � 2. Nam� oss p�rmit/7►TC it Di!l�r�nt thaa Abow �4(G� µ��/��B��}� � Mailiaq ltiddr�u 'City/Stat�/81p 3. Appiicatioa For: Site Evaluatioa �� @�Smprovament Permit/ATC ❑ Both a. sy,t.m to s.�o.: 0 House E�[�"Mobile Home 0 Business � Iadustry ❑ Other �iJgc.E W f�G` s. s� Residenca: i .Paople '-F � Bedrooms _y� , i Bathrooms � �'Dishwash�r ❑ Garbaq� Disposal 6'SPashinQ 1lsohin� � Baa�at/plumbiaq � Sas�masst/No plumbiaq 6. I! Husin�ss/Indwtsy/Otturs Sp�oily typ� � P�opl� � Sinlc� � Commod�s � ShoK�rs i Uriaals # Rat�r Cool�rs iP' FOODSERVZCE: # Seats Estimated �Pater Uaagn (�ious p.r aay) �. Type ot water suppiy: B�Couaty/City D Woll [] Community e. Do you anticipate additions or eapanslons of the facllity this system Is intended to serve? 0 Yes fiYl'�o If yes,what type? ***IMPORTANT***CLIENTS MIIST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED BELOW. Either a PLAT or SITE PI.AN MIIST BE SUBMITTED by the client wlth THIS APPLICATION. Property Dimensions: '��-`�`--� WRITE DIREGTIONS(from Mocksville)to PROPERTY: Taz Office PIN: # S�3�S3 9� � � /�7' � 5� �-�� v'-�-X�a,`�"� - Property Address: Road Name /POSE �,6 0�- �--� �n � /� �� . , c�ty�ztp d►�o �,�s JI L L E � - �,��,- rX �/Yx.c-�-P, �o�-,�-� �"�"O� � �.!-�, ��^-e-, If in a Subdivision provide information,as follows: � Name: Section: Block: Lot: Date Property Flagged: � �z�-`t'S This is to certify that the information provided is conect to the best of my knowledge. I nnderstand that any permit(s) issued hereafter are subject to saspension or revocation,if the site plans or intended use change,or if the informaHon submitted in this application is falsif�ed or changed I,also,understand that I am responslble jor all charges lncurred from thls application. I,hereby,give consent to the Authorized Represeatative of the Davie County Health Department to enter upon above descrIbed property located in Davle Connty and owned by �L�� R ��'K �� to conduct all testing procedures as necessary to determine the site snitabillty. DATE � '�O �nl � SIGNATURE L�� • ��— THIS AREA MAY BE USED FOR DRAWING YOUR STTE PLAN(Include atl of the following: Ezisting and proposed oroperty llnes and dimenslons, structares, setbacks, and seutic locations). � �-^ _ � Site Revisit Charge ol��e_ Date(s): Client NotificaHon Date: EHS: Account Na �� Revtsed DCFID(07/99) - Involce Na �� v v.. 557 Q^W c / � PLANNING AND ZONING / a �UNt / JOHN S. GALLIMORE � oiaECToa 521 �qVIE GOl1NTY A�MINISTRATION BUILOING �� 23 SOUiH Mnw Sr., Room 307 OFFicE�. 336-�51-3340 MOCKsvi�LE, NG 2�028 Fn%: 336-751�449] � 1 1 6 i i ;�,�Q 138 115 14 \` / �TVL � I� �y� � O � ��9-� . �� 174 , �z'� �u� -� M�� e �� ; � �-�� \ Sz,�r � � ,_ . 433 f U w � �� C[�z a n i-ri `� � ,t�T .ri , C 7 c-, �-c 1�e'�. ••fL � 417 \� � <, t,.v cS ( ` i�'_ 451 40� ;�Y�� ,,,,<:, — , ` 3 m s,�, �z��ti� � J . � ` ' � 12, �» � �� - a . :'� S fj '_: ., , i ' � " 1os '"' Z� �\o I � -�': �" _ � � �' � - rn� , i .� �� . � � _ � o � , .��+ , �`� �I �`I �+ ��-� � . vt LB�� :: ,`\a � � (Q�' � �n c �'� � �\;� �' m i-•� :n �..�j ''7 . . �+" a �, .4 iOrr� st ' w' z ��„'�� ' p� .M r' c �n� '�'�' V '��# � � � � �u � in ,c �-,"�o' p - - � -- - -- �� : Q �. 1 2� ,r._ . � tl - , °', N I '_ c\ ��' f� �' 2� 'sd � _ __ . . „ ' �- U �. /�� y�o. ..� , . ; � zun � � in � . �, i,. � �R �.� ..' -. . , .':., S � ie .: I ' � 'I ` c� / �� : ,pt!.i .� ..� '., * � . �i _'. .� /., ` � `�� Jt y� �. . � �. . }1. . 3 � " r 0 . . _ � , . P �/hQy �:' i . ��cv`o ' � a �`�: � � :i w � � l \ r �{Y� ./ �, w , . .� n2 d � ` I / ` � � � Y� �q �6`. /�' G 4f'��r � r. . . A 1 � � � ti � �..t �.� 8`'.r' CJ.. . _ �, L(� 3 � � .� I •. � :. ' N' , ". I � #� „��. � �1 �y :� C'<"� . O � . � .;,':+� �:l�,t �r � :r m rn �'r : � . �, � � 7 ... �... 2 � �. . a -� ;l� �u.,� N � .�".[� � ' ��.�.. '�6/ /J . .� ... J . , '.~ � 3._.W r° . . .y . . . • . ,�. � -�.. � a ..., �� . .. q"' ; .. . Q n+ i�``,� ' . ,,� , . .F : � ,� -•�' . � v t A ., N � ,�� .,. , � �d . x O � "�` ` �� s,, � .,:s ;:� � . f�, °' ",; m ":�r . . � N ,[�,�t�r ' �r, �. ,�, . s��z� " 5;:` ',�;9LI -'\/) ,n� t^Y"Y. . N � �lE'��. , "tu�/�- 2 i c �� _ . � A�X'iy�:.. ..., w , �.�t,b6� �� ' " .. �� .V:.uo �� / � .. , . r.":� . :r • .�-� �f'�TMY �rm�.,.- - �4/N \ � ti: •�. �,"' �., ., 4�, :"� �:,wti •- � ti j t ry . ' . . ,'„��a9 . ,F �� :� .�' � �� 4 ,«,w .�'�Pp.L , .'r' ' r > � 1 � 4J� t ��. Y q �� 1 f� k:a� ��ll� : . '- . - ft ! �� 1 u�r-sc'�M[ yy�,�,� , :�y':.. � - .,. �� .. ..;. . . . p ., Y. � �fl�{�) � Y.�. . : . . �r'�� ';4 1' , ,y�;� <,� Y � �4 . _ � I yy� "� 1 J � 'V v �r. � ,°� � . ' xr. H � � � '�a y�'W � f•�'.�. 1 6 0 ..�.' t n ..k:i�., �� ' � . .� _. l� V' �r' y''P^,.� � � �I ..K , M 4.. . . ''y�,� y '. ' . "..s� ��.. ',r�(L � �1�•,'+N' � t �.s-ti f . s � ..�+' - � . " ��t'�'r u .�,� •p.f. ei�;.,., .,. . , �. ,.Y M � � .� _.+�5, '_ _� . . _ ".wL't ....Ia._ . . . t, ,. , ., llAVIE CUUNTY HEALTH DEPARTMENT ��y� y } � � ' Environmental Health Section . ,r ' Soi�/Site Evaluation APPb.ICANT INFORMATION PROPERTY INFORMATION Account #:� 989900636 Tax PIN/EH#: 5758-53-9642 Billed To: Alicia Bean Subdivision Info: Reference Name: Alicia Bean Location/Address: Rose Arbar Lane-27028 Proposed Facility: Residence Property Size: 24.5 Acres Date Evaluated: � ��i� ��— WaterSupply: On-Site Well Community_t./ _ Public Evaluadon By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landsca sidon Slo % HORIZON I DEPTH ... _ ..� Texture rou Consistence Structure (� Mineralo �� HORIZON II DEPTH �. � Texture tou Consistence � S S Swcture Mineralo HORIZON III DEPTH " � Texture rou Consistence Structure Mineralo � � HORIZON IV DEPTH Texture rou Consistence Structure Mineralo SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE . CLASSIFICATION LONG-TERM ACCEPTANCE RATE , , SITE CLASSIFICATION:P� EVALUATION BY: d`'�/�-``�--� LONG-TERM ACCEPTANCE RATE: • OTHER(S)PRESENT: REMARKS: � ` �� , LEGEND ' andscaoe Position � R-Ridge S-Shoulder L-Lineaz slope FS-Foat slope N-Nose slope CC-Concave slope CV-Convex slope T-Temace 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 � NS-Non sticky SS-Slighdy sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic t ure � SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angulaz blocky ' SBK-Subangulaz blocky PL-Platy PR-Prismatic inrl 1:1,2:1,Mixed � ' te Horizon depth-In inches t 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-gaUday/ft2 ' bCHb (27evised 05/99) .,w,i-,y.-...�,�,. .'�".<, --,z. =..r'"" ., ....-<r ^e+'as; � . ., . . 'J- . .�_ . — a . . -. .. . � -. .. .. -. _ - .-- ., ' ° - _ . . , -.,. -- . .. .... , . . .... -., - . . y . s . .,.. ....... . .. .. _ , . - ... � :J - � r *-�t=% : , ' ;. . _ . ",c�� -��' � DAVIE COUNTY HEALTH DEPARTMENT B �-%� �-� � �'`�, `��-""'` —= IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION �1'�� M a/;"':,; .�.r_�----•`� �, • �-��"�JOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) P@I'1111t Nlll11be1' � Name 1[.��,;��t��-r7�;r�:;:,r Date �lJ�9�B''� N� ��i.7 t i� Location �f/~- /,=/T;��,r��'C-yt^� ;�- C" Ir . � ' ;� �/ .�� ,•. �� ; { �% i��` � `'I /PD�s�` ��'��D��r•�/V� � `� Subdivision Name Lot No. ` ° ; Sec. or Block No. Lot Size �-��C House�_ Mobile Home _ Business Speculation � . No. Bedrooms �� No. Baths�� No. in Family� Garbage Disposal YES � NO .�]' Specifications for System: Auto Dish Washer YES NO ❑ ,�/� /�'D!�G�� .�� Auto Wash Machine YES �j NO �❑ � TYPe Water Supply � _ c��l�ir..i i'�/.:�'��i�� *This permit Void if sewage system described below is not installed within 36 months from date of issue. � . - . . I i I i � r _ �� Improvements permit by — r�2f� *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 � + ( J � 1= ._. --- � - — 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 given period of time. �--- t " �. 4 t ` � , . .�.A ' I , ; = . �. ' ' APPUCATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT . : Davie County Health Department Q M�R 2 � � �� Environmental Health Section R��V� n�C�J � P. O. Box 665 uJ Mocksville, N.C. 27028 �� 4'`7� � /J�,f �STRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. �Cl Home Phone 1. Permit Reque ed By d � �'�"- -� Business Phone 2. Address � � �-• d 3. Property Owner if Different than Above H o'�-i — Address 4. Permit To: a) Install Alter Repair_y.- b) Privy Conventional j�her Type 1 � Ground Absorption N o t�i7� a F Lc�— ('F+�N�,�� c) Sub-Division �=�5� � • Sec. Lot No. 5. System used to serve what type facility: House obile Home Business Industry Other b) Number of people `� 6. a) If house or mobile home, state size o home and number of rooms. House Dimensions �� Bed Rooms ,� Bath Room �Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) . , 7. Number and rype of water-using fixtures: commodes -3 urinals � garbage disposal lavatory 3 showers �" washing machine � dlshwasher 1 sinks � 8. a) Type water supply: Public �- Private Comrnunity b) Has the water supply system been approved? Yes ��o 9. a) Property Dimensions �� "F� b) Land area designated to building site 1�� 1� � '�?� c) Sewage Oisposal Contractor ? � 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What rype? This is to certity that the information is correct to the best of my knowledge. �—o`L � `�7 f^ ..� �y-�J Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Dfrections to property: �� V �� . � �{,� /��r�. . � ' ' Z n F �� `il� y.�G� �j't°G�' � V ' � � ��j"�' �i�,L Ft91�� .� , L7{h$ t 9� � � Y`L Co-.-�v�4 T Z E/` l�'C�(. r� 'h @�� \ �` V -��.��- �� ,� , . Q ��s�r . ��`� - �;, ,J` w� . 4 �s . �!.�c.,.,_ ��.ti ��' � f rv�\ ?'� " 'J{% ' DCHD(6-82):,,�� . / � f. ,. '� y' ,. i � . ;�.♦ ,_ � , , ' . '. ' DAVIE COUNTY HEALTH DEPARTMENT .. Environmental Health Section ' P. O. Box 665 � Mocksville, N.C. 27028 SOIL/SITE EVALUATION �' Name Date �� Address Lot Size �SI��'�� FACTOR$ AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S (�S�j PS PS PS 17� U U U 2) Soil Texture (12-36 in.) Sandy, ,, S � S S S Loamy, Clayey, (note 2:1 Clay) P PS PS PS U U U 3) Soil Structure (12-36 in.) S S S Ciayey Soils �� PS PS PS U U U U 4) Soil Depth (inches) S S S S pg PS PS PS U U U 5) Soil Drainage: Internal � S S S PS PS PS U U U U Extemal S S S � PS PS PS � U U U U 6) Restrictive Horizons `�/� L 7) Available Space S S� S S g PS PS PS � � U U U 8) Other (Specify) S S S S pg PS PS PS V U U U 9) Site Ciassification , U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: �� o��"' . 1!-�r ��1.� ��J_ C`�� r�/�8 Described by��i Title ,�/"� /� Date Y � SITE DIAGRAM jr . ;� I � � 1 � � � / DCHD(6-82) . � � � �+ � .