137 Williams Way'f
DAVIE COUNTY- HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND. CERTIFICATE OF COMPLETION
*NOTE:'Issued in Compliance With Article 11 of G.S. Chapter 130a
Sanitary Sewage Systems tzcs Permit Number
Name Date 1� !� N'
0
Location "C \ �� `f. WN t, 1\:1!:.1\:1!:.,•A\ - 6765
LA
Subdhi §ion Name ._3 Lot No. _ Sec. or Block No.
Lot Size , = n House Mobile Home Business Speculation
No. Bedrooms -5 No. Baths No. in Family —
Garbage Disposal YES ❑ NO p-' Specifications for System:
Auto Dish Washer YES 0-. NO ❑ t; ,, f.� - , r, V2)
Auto Wash Ma :hive YES Ey' NO ❑ {
Type Water Supply Ct ..;��, -�, j-r;�c`A:
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to. revocation if site plans or the intended use change.
i
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
Certificate of Completion-`�-- Dated" /
"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.
y!
APPLICATION FOR SITE EVALUATIOWIMPRO'
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested B �j An1AU V.POl�S J f R .1 ox 2-22- !� Moc( OkeM,
Mailing Address �
Home Phone 997— 5 O 5(a Business Phone CC
2. Name on Permit if Different than Above
3. Application/Permit for: \— ❑ General Evaluation
4. System to Serve: `E House ❑ Mobile Home
❑ Business ❑ Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms 3
No. of Bathrooms FL,(, I I
Dwelling Dimensions 1100 s 1y
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
APR 2 91992
laag
g - 4 90 q
�7 Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
� Basement/No Plumbing
\2 Washing Machine
i� Dishwasher
. No. of Showers Water Usage Figures
7. Type of water supply: "r�] Public ❑ Private
8. Property Dimensions ac/ ff Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this,sytem is intended to serve? \Ei Yes
If yes, what type?
1 i n bas m vh-�
❑ Garbage Disposal
❑ No
❑ Community
*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: I f o (b e g d m otO Kdt J ib-endm qN ( d t to TA R
1of °J fl60V.� j/z m�1�, fT2s+ mdbi(�_ borne oM
'uc2u i n JKk AY besk,k of mobile. ki _ d 1 ��W �y hof j s
�0 +w— � j � o -F exkaWN wood a.O0f y bvAs f ma t2 kd w ifih
o+�AN�e V6 b61,1 , �ouSQ `l �t k 3 51 �hfl� wi�l 10 LA
V(a m���1e o� lobo
This is to certify that the information provided is correct to the
incurred from this application.
lora ��
-26
DATE
my knowledge, and I understand I qm responsible for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
\
MUST CHECK ONE: `n 1. 1 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 representativ f the Da ie oun Health Dep rtment to enter upon above described
property located in Davie County and owned by �C" U 1 �YZr7 A S IUM
M
to conduct all testing procedures as necessary to determin7s'd site's suitability for a ground absor tion sewage treatment
and disposal system.
y APRt'i a(o /942.
DATE SIGNATURE
DCHD (12-90)
NAME _ <;
ADDRESS AP
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
PROPOSED FACIILTY �X o u s
DATE EVALUATED
PROPERTY SIZE C.,
LOCATION OF SITE got S
Water Supply: On -Site Well Community
Evaluation By:t IA- Auger Boring ✓ Pit
Public
Cut
FACTORS
1
2
3
4
Landscape position
S
S
S
Slope %
- r°
c6 - 5
s� - J5
- IS
HORIZON I DEPTH
Texture group
Consistence
-
Structure
V,G
R
Mineralogy
1;j
HORIZON II DEPTH
42'
Texture groupt-
CL
CL
S C �—
Consistence
t= R
(Z
F
Structure
Z
C R
F
Mineralogy
7. 1
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
S'
S s
S
s
SAPROLITE
5
S
CLASSIFICATION
S
S
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: S EVALUATED BY:_ �C!
LONG-TERM ACCEPTANCE RATE: OTHERS) PRESENT:
REMARKS:
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
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
DCHD(01-901
■
■■
MEMO
■EO■
Parcel #: L60000005802
Davie County, NC - Basic Estate Search
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Parcel #:L60000005802
Account #:70483000
Information
Tax Codes
ADVLTAX -COUNTY YT
FIREADVLTAX - FIRE TAX
L137Owner
RY SAMUEL CROTTS& SPRY LINDA G
WILLIAMS WAY
OCKSVILLE NC 27028
BXF•
47
Property Information
Township
(Units/Type): 1.000 AC
Ess:137 WILLIAMS WY
JERUSALEM
ssessed:
171,54
eferred:
Deed Information
Local Zoning
Date: 03/1992 Book: 00162 Page: 0928
Plat Book: Page:
Le al Description
PIN
1.00 AC OFF HWY 801
5756965563
Property Values
Buildin
160 01
BXF•
47
Land•
11,06
Market:
171 54
ssessed:
171,54
eferred:
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
1 00162 0928 03 1992 WD Unqualified Vacant 0
View Property Record for this Parcel View Map 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,
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implied, in factor 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/itsnet/View.aspx?prid=1481641 8/31/2016