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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Arjj icle I I of G.S. Chapter 130a
Sanitary Sewage Systems i! l/~
Name • //Fr rit%�/�'''�tl/? /%,i %j �>r'%� /—/'-/Date
T
Location &;1611-) --
F
Permit Number d�L
N° 7 8 4 4
�jj.��r
Subdivision Name
Lot No. Sec. or Block No.
Lot Size
House
Mobile Home _— Business
Industry
No. Bedrooms �L�
No. Baths -4??__
No. in Family Public Assembly
Other
Garbage Disposal
YES ❑ NO
Specifications for System:
Auto Dish Washer
YES ❑ NO
Auto Wash Ma :hive
YES ❑ NO
Type Water Supply
*This permit Void if sewage system descri�
tans
nstaittd-vvithin�years from date of issue.
This permit is subject to revocation if site
or the intended use change.
F
64
v 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.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by
cvb1gly 19 if
eul
121).-e
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PE"RECEIVED
4 �t Davie County Health Department
•; Environmental Health Section IA r; -11995
P. O. Box 665 d
Mocksville, NC 27028
1. Application/Permit Requested By ACom/
C',//
1a66X-1'11 !4Mailing
/4
z5OX �-
Home
Address �'�'0,
/1'10 Gil l •l /d G Z Z4 Z-P
Phone
4
Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation
Veptic Tank Installation Permit
4. System to Serve: ❑ House ❑
Mobile Home ❑ Place of Public Assembly
4,tlo'Business ❑ Industry ❑
Other ❑ Unknown
5. If house, mobile home: Subdivision
Section Lot #
No. People ►�'
❑ Basement/Plumbing
❑ Basement/No Plumbing
of
No. of Bedrooms
❑ Washing Machine
No. of Bathrooms
❑ Dishwasher
Dwelling Dimensions
❑/Garbage Disposal
6. If business, industry, place of public assem I other: Specify type
No. of People Served
No. of Sinks
-2"
No. of Commodes
No. of Urinals
/
No. of Lavatories
No. of Water Coolers
No. of Showers//
Water Usage Figures
7. Type of water supply: P'Public
❑ Private ❑ Community
8. Property Dimensions / Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Q" No
If yes, what type?
"NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
Ao�
This is to certify that the information provided is correct to the best of my kno ledge, and I underste
incurred from this ppli � n. _ zfz� 5f;�
DATE SIGNATURE
responsible for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: Ld'1. I OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
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
to conduct all testing procedures as necessary to determine said site's itability for a. ground absarption sewage treatment
and disp al sys M.
DATE SIGNATURE
DCHD (1/93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME //UG!
ADDRESS
PROPOSED FACIILTY%y`Ss
Water Supply: On -Site Well
DATE EVALUATED
PROPERTY SIZE
1A
LOCATION OF SITE
6�fS
Community
Public Z_ --
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4
Landscape position L L
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH f'
Texture group
Consistence
Structure "e Sh/c L/
Mineralogy/
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: _ �J�` / EVALUATED BY: /`/Q `/
LONG-TERM ACCEPTANCE RATE: - 7 OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
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
3C -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
DCHD(01-901
Parcel #: J5090A0013
Davie County, NC - Basic Estate Search
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View Prooerty Record for this Parcel View Mao for this Parcel View Tax Bill Information
Parctai #: 15090A0013
Owner Information
FULLER PHILLIP EDWIN JR
92 BUCK SEAFORD ROAD
MOCKSVILLE NC 27028
Property Information
Land (Units/Type): 1.980 AC
Eddress: 980 SALISBURY RD
Deed Information
Pate: 02/1994 Book: 00172 Page: 0819
Plat Book: 0001 Page: 091
Account #:28144000
Tax Codes
ADVLTAX - COUNTY T
FIREADVLTAX - FIRE TAX
Township
MOCKSVILLE
Local Zoning
Le al Description PIN
LOTS 147-150 JACOB EATON I 5737884177
Property Values
Building:
76
BXF•
3]1,28
Land•
6
Market:
85
18nessed:
85
Deferred:
3
Sales Information
No.
Book Page Month Year Instrument
Qual/UnQuai
Improved Price
1
00091 0692 10 1973 WD
Unqualified
Vacant 0
2
00167 0252 02 1993 QC
Unqualified
Vacant 0
3
00172 0819 02 1994 WD
Qualified
Vacant 40,500_
View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information
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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.daviecountyne.gov/itsnetfView.aspx?prid=1477647 7/19/2016