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159 Cedar Forest Ln Lot 40 Davie County,NC Tax Parcel Report Thursday,November 10, 2016 1J1 ------------------ JJ FF J . Z __--_--_— — _ -t 4 - r^ 1 • w ` Q` 159 O LLU 169 I WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number C513OA0007 Township: Farmington NCPIN Number: 5842972141 Municipality: Account Number. 82530768 Census Tract: 37059-802 Listed Owner 1: FEDERAL HOME LOAN MORTGAGE COR Voting Precinct: FARMINGTON Mailing Address 1: 3476 STATEVIEW BLVD Planning Jurisdiction: Davie County City: FORT MILL Zoning Class: DAVIE COUNTY R-20 State: Sc Zoning Overlay: DAVIE COUNTY QD Zip Code: 29715-0000 Voluntary Ag.District: No Legal Description: LOT 40 CEDAR FOREST Fire Response District: FARMINGTON Assessed Acreage: 0.48 Elementary School Zone: PINEBROOK Deed Date: 11/2015 Middle School Zone: NORTH DAVIE Deed Book/Page: 010060116 Soil Types: IrB,EnB Plat Book: 0005 Flood Zone: Plat Page: 006 Watershed Overlay: DAVIE COUNTY Building Value: 111250.00 Outbuilding&Extra 4720.00 Finatures Value: Land Value: 25000.00 Total Market Value: 140970.00 Total Assessed Value: 140970.00 161 Ag data is provided as Is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the Davie County, Impliedwaran es of merchantability orfitness for a particular use.Ati users of Davie County's GIS websiteshall hold harmless the County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to NC - or arising out of the use or inability to use the GIS data provided by this website. OPERATION PERMIT EEvaluatedFor use Only Davie County Health Department r 199348-1 ♦�Lo f- 210 Hospital Street P.O. Box 848 . Mocksville NC 27028 PAIR Phone:336-753-6780 Fax:336-753-1680 Applicant: Jerry Blackwelder Property Owner Jerry Blackwelder Address: 159 Cedar Forest Lane Address: 159 Cedar Forest Lane City: Mocksville City: Mocksville StatefZip: NC 27028 State/Zip: NC 27028 Phone#: Phone#: Pro a Location & Site Information Address/Road#: Subdivision: Cedar Forest Phase: Lot: 40 7 159 Cedar Forest Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY hwy 158 left on Farmington Rd. to end turn right on Hwy 801, then right on Cedar Forest Lane #of Bedrooms: 3 #of People: *Water Supply: PUBLIC *IP Issued by. 'System Classification/Description: TYPE II A CONV SYSTEM(SINGLE-FAMILY OR 480 GPI]OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? OYes ONo Design Flow: 3 6 . 0 'Distribution Type: GRAVITY-PARALLEL(eq.d-box) POYeseQNo? Soil Application Rate: 0 a *Pre Treatment: Drain field (N7knificationd Sq.fi• *System Type: EZFLOW EZ 1003T 4 Installer: Brett McMahan oarencength: 2 8 0 ft. Certification#: Trench Spacing: — g ()Inches t O C.0 *EHS: 2140-Nations.Robert Trench Width: — 3 Olnches • Feet Date: 0 2 / a 9 / a 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover. a 4 Approval Status Inches , Maximum Trench Depth: 3 6 Inches ® A'\, pproved D Disapproved Maximum Soil Cover 2 4 Inches r CDP File Number 199348 - 1 County ID Number: Septic Tank Manufacturer. Lat. - STB: Long: Gallons: installer Date: / / Certification#: THS: *Filter Brand: ST Marker. ❑ Yes ❑ No Date: Approval Sfatus Reinforced Tank: ❑ Yes ❑ No - 1 Piece Tank: ❑ Yes ❑ No ❑ Approved❑ Disapproved Pump Tank Manufacturer. Installer. PT: Certification#: Gallons: THS: Date: / / Date: RiserSealed ❑ Yes ❑ No RiserHeght: ❑ Yes ❑ No (Min.6in.) ApprvalStatus einforced Tank: ❑ Yes ❑ No p Approved❑ Disapproved 1 Piece Tank:_ ❑ Yes ❑ No Supply Line Pipe Size: inch diameter Installer Pipe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ No Approval Status = ❑ Approved❑ Disapproved _.ter Pump u e ( Pump Type: Installer. Dosing Volume: — Gal Certification#: Draw Down: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ No Flow Adjustment Valve ❑ Yes ❑ N o Check-valve ❑ Yes ❑ No Approval Status= PVC unions El Yes ❑ No ❑.Approved L7 Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes 0 NO r .CDP File Number 199348- 1 County ID Number: Electric Equipment NEMAT4XBox or Equivalent ❑ Yes ❑ No Installer. Box 1Above Grade ❑ Yes ❑ No • Certification#: BTo Pump Tank ❑ Yes ❑ No Conduit Sealed ❑ Yes ❑ No *EHS: Pump Manually Operable ❑ Yes ❑ No *Activation Method: Date: Approval Stafus Alarm Audible ❑ Yes ❑ No p,Approved El Dsapprwed Alarm Visible ❑ Yes ❑ No 2140•Nations.Robert *Operation Permit completed by: Authorized State Age Date of Issue: 0 3 / 0 1 / a 0 1 fit Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11,Chapter 130A, Rules for Sewage Treatment and Disposal, 15A NCAC 18A .1900 et. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE II A sewage septic system. Rule.1961 requires that a Type TYPE ll A. septic system meet the following criteria: Minimum System Review ByThe Local Health Department: N/A _ Management Entity: OWNER 777 Minimum System Inspection/Maintenance Frequency ByCertified Operator: N/A Reporting Frequency By Certified Operator.N/A Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract with a public management entitywrth a certified operatoror a private certified operator forthe life of the septic system. Rule.1961 requires that Type VI septic systems designed fora home/business owner must maintain a valid contract with a public management entdywith a certified operator forthe life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator,provisions that the contract shall be in effect for as long as the system is in use,and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. GHand Drawing Olmport Drawing **Site Plan/Drawing attached.** • OPERATION PERMIT 199348 - 1 Davie County Health Department CDP File Number: 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: / 1 r r a Q Inch 0131oDrawing Drawing Type: Operation Permit Scale: . ON/A = ft. QN/ i I f f a ) I� us � uc f II f fI I OPERATION PERMIT or ice se nv a Y Davie County Health Department 'CDP File Number 199348-1 3 210 Hospital Street P.O. Box 848 County ID Number: Mocksville NC 27028 Evaluated For. REPAIR Phone: 336-753-6780 Fax: 336-753-1680 Township: Applicant: Jerry Blackwelder Property Owner. Jerry Blackwelder Address: 159 Cedar Forest Lane Address: 159 Cedar Forest Lane City: Mocksville City: Mocksville State/Zip: NC 27028 State/Zip: NC 27028 Phone#: Phone#: Property Location & Site Information Address/Road#: Subdivision: Cedar Forest Phase: Lot: 40 159 Cedar Forest Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY hwy 158 left on Farmington Rd. to end turn right on #of Bedrooms: 3 Hwy 801, then right on Cedar Forest Lane #of People: *Water Supply: PUBLIC *IP Issued by: *System Classification/Description: TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) *CA issued by: 2140-Nations,Robert Saprolite System? 0 Yes ®No Design Flow: 3 6 0 *Distribution Type: GRAVITY-PARALLEL(eq.d-box) Pump Required? Yes No Soil Application Rate: 0 . a *Pre-Treatment: Drain field r cation Field Sq.ft. *System Type: EZFLOW EZ 1003T rain Lines 4 Installer: Brett McMahan Total Trench Length: a 8 0 ft. Certification#: Trench Spacing: _ 9 Q Inches O.C. 0 Feet O.C. EHS: 2140-Nations,Robert Trench Width: 3 0Inches _ ®Feet Date: 0 a / a 9 / a 0 1 6 Aggregate Depth: inches Minimum Trench Depth: 3 6 Inches Minimum Soil Cover: a 4 Approval Status Inches Maximum Trench Depth: 3 6 ® Approved❑ Disapproved Inches Maximum Soil Cover: a 4 Inches Page 1 of 4 CDP File Number 199J48 - 1 r Septic Tank County ID Number: Manufacturer: Lat. STB: Long: Gallons: Installer: Date: Certification#: *EHS: *Filter Brand: ST Marker: ❑ Yes ❑ No Date: Reinforced Tank: El Yes El No Approval Status oed 0'. Disapproved ❑ Appry 1 Piece I ank: ❑ Yes ❑ NO Pump Tank (Manufacturer: Installer: PT: Certification#: Gallons: *EHS: Date: Date: Riser Sealed ❑ Yes ❑ No Riser Height: ❑ Yes_ ❑ NO (Min. 6 in.) - = Approval Status, Reinfd Tank: ❑ Yes ❑�� � NO '901-IF❑ Disapproved 1�PieceTank: ❑ YeS O Supply Line Pipe Size: inch diameter Installer: Pipe Length: feet Certification#: *Schedule: *EHS: Pressure Rated ❑ Yes ❑ No Date: Approved fittings ❑ Yes ❑ NO Approval Status ❑'Approved❑ Disapprovetl Pump Requirement CDos'lng Type: Installer: lume: - Gal Certification#: rawDown: Inches *EHS: *Chain: Date: Valves Accessible ❑ Yes ❑ NO Flow Adjustment Valve ❑ Yes ❑ NO Check-valve ❑ Yes ❑ No Approval Status PVC unions ❑ Yes ❑ No ❑ Approved❑ Disapproved Vent Hole ❑ Yes ❑ No Anti-siphon Hole ❑ Yes ❑ No Page 2 of 4 CDP File Number 199348 - 1 County ID Number: Electric Equipment FBox A 4X Box or Equivalent ElYes ElNO Installer: 2 inchesAbove Grade ElYes E] NOCertification#: ox Adj.To Pump Tank ❑ Yes ❑ NO Conduit Sealed ❑ Yes ❑ NO *EHS: Pump Manually Operable ❑ Yes ❑ NO *Activation Method: Date: Approval Status Alarm Audible ❑ Yes ❑ No ❑ Approved❑=Disapproved _j Alarm Visible ❑ Yes ❑ No 2140-Nations,Robert *Operation Permit completed by- Authorized State Ag Date of Issue: 0 3 / 0 1 / 2 0 1 6 Owner/Applicant Signature: This system has been installed in compliance with applicable NC General Statutes:Article 11, Chapter 130A; Rules for Sewage Treatment and Disposal, 15A NCAC 18A.1900 et. Seq.,and all conditions of the Improvement Permit and Construction Authorization.This property is served by a TYPE n A. sewage septic system. Rule.1961 requires that a Type. TYPE ii A. septic system meet the following criteria: Minimum System Review By The Local Health Department: N/A Management Entity: OWNER Minimum System Inspection/Maintenance Frequency By Certified Operator: N/A Reporting Frequency By Certified Operator: N/A Rule.1961 requires that a Type IV and V septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator or a private certified operator for the life of the septic system. Rule.1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a public management entity with a certified operator for the life of the septic system. Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the issuance of an Operation Permit for a system required to be maintained by a public or private management entity, unless the system owner and certified operator are the same. The contract shall require specific requirements for maintenance and operation, responsibilities of the owner and systems operator, provisions that the contract shall be in effect for as long as the system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of the Operation Permit that subsequent owners of the systems execute such a contract. ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 3 of 4 OPERATION PERMIT 199348 - 1 Davie County Health Department CDP File Number. 210 Hospital Street P.O.Box 848 County File Number: Mocksville NC 27028 Date: / / O Inch 'Drawing Drawing Type: Operation Permit Scale: . OO Mock ft. ......................................................................................r.................i...................................---- ............................... ................. I ..... 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L j .................................. _..........:........... ........... ............................ .................................................. ...... ........................_ ._, . ................;.................................. ............................ .......... !. . _.. . �....._ 1 _ .............................-I I i ................. 1................ 7 .. �.........._..... d.........{. r ` ........ .....................................................I ... .... ............................... . ................................. .........a .. .. ...... :. ... .f i. ........ ........ .............. ..... .. .... ................... ......... ......... ......... ^ ...... i ................................... .... ...................... � 0 I ( ( 1 .............................................................................................i.. . ....._.....................................................................................................................................i.................................. .............. ............... ............................... ....................................... ...... j ..................................................................................................... ... .....:................................................................,................. ............................. .............. .. . .......... ..............................._.................I..................................................,................;.................1...................................................;.................................,...................---...........................�............. i .................. j Page 4 of 4 P1 P2 P3 CONSTRUCTION AUTHORIZATION Davie County Health Department 210 Hospital street CDP File Number: 199348 - 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: .0.1./ 14 / .2 0 16 Click below to import an image from an external location: Drawing Type:Construction Authorization � J o �1 d J e M V �l P1 P2 l �' CONSTRUCTION AUTHORIZATION 4 Davie County Health Department CDP File Number: 199348 - 1 210 Hospital Street P.O. Box 848 County File Number: Mocksville NC 27028 Date: 01 / 14 / a016 0Inch Drawing Drawing Type: Construction Authorization Scale: , 0 Block 0 N/A ' - i I � . ...__._.....__ --- _____.....----------- _____--- - --- ---- -.. -- -- ---.... ..` --......_..._..._ L ... ........ - _ � - _ --_ --- ...... __ _ - _ - ---- ---._........ I ice_ o_ ........ - -- t - .. ...._._ --- __........ _..._......... __- Page 3of3 P1 P2 CDP File Number 199348 - 1 County ID Number: ❑ Open Pump System Sheet Repair System Required:0 Yes ONO ONO, but has Available Space rDesignFlow:**** System Trench Spacing: O Inches O. . ification: — O Feet O.C. 15A NCAC 1 �,—..wl945 **** Re tes Soil Application Rate: Aggregate Depth: inches .� Minimum Trench Depth: *System Classification/DescriRepair Area Zx+e II � Inches Inches Maximum Trench Depth: *Proposed System: Inches Maximum Soil Cover: Nitrification Field Inches Sq. ft. No. Drain Lines *Distribution Type: Total Trench Length: ft Pump Required: OYes O No O May Be Required Pre-Treatment: O NSF OTS-I OTS-II *Site Modifications No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department. Rem-'ns_. 750 *Permit Conditions The issuance of this permit by the Health Department in no way guarantees the issuance of other permits. The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. Rama`m There isn't enough available space to a full repair.Istall as much system as space and setbacks allow. 1897 This Authorization for Wastewater System Construction shall be valid for a person equal to the period of validity of the Improvement Permit,not to exceed five years,and may be issued at the same time the Improvement Permit issued(NCGS 130A-336(b)).If the Installation has not been completed during the period of validity of the Construction Permit,the information submitted in the application for a permit or Construction Authorization is found to have been incorrect,falsified or changed,or the site Is altered,the permit or Construction Authorization shall become Invalid,and may be suspended or revoked(A 937(g)).The person owning or controlling the system shall be responsible for assuring compliance with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? O Yes O No Applicant/Legal Reps. Signature- Date: *Issued By: 2140-Nations,Robert Date of Issue: 0 1 / 1 4 / a 0 1 6 Authorized State Agent: Malfunction Log OYeS ®Hand Drawing O Import Drawing **Site Plan/Drawing attached.** Page 2 of 3 CONSTRUCTION For office Use only AUTHORIZATION *CDP File Number 199348- 1 •'`""F` Davie County Health Department County ID Number: J 210 Hospital Street Evaluated For: REPAIR .� e. P.O. Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone: 336-753-6780 Fax: 336-753-1680 0 1 / 1 4 / .2 0 2 1 Applicant: Jerry Blackwelder Property Owner: Jerry Blackwelder Address: 159 Cedar Forest Lane. Address: 159 Cedar Forest Lane City: Mocksville City: Mocksville State/Zip: NC . 27028 State/Zip: NC 27028 Phone#: Phone#: Property Location & Site Information Address/Road#: Subdivision: Cedar Forest Phase: Lot: 40 159 Cedar Forest Lane Mocksville NC 27028 Directions Structure: SINGLE FAMILY hwy 158 left on Farmington Rd.to end turn right on Hwy 801, then right on Cedar Forest Lane #of Bedrooms: 3 #of People: *Water Supply: PusLlc System Specifications Minimum Trench Depth: a 4 rDesign ation: Provisionally suitable Inches Minimum Soil Cover: 1 a tem? O Yes 68)No Inches 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons *Proposed System: 25%REDUCTION 1-Piece: O Yes O No Pump Required: QYes (&No O May Be Required Nitrification Field 1 8 0 0 Sq.ft. Pump Tank: Gallons No. Drain Lines rJ 1-Piece: QYes ONo Total Trench Length: 4 5 0 ft GPM--vs— ft. TDH Trench Spacing: O Inches O.C. _ g ®Feet O.C. Dosing Volume: Gallons Trench Width: _ 3 OInches ®Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: O NSF OTS-I OTS-II Septic Tank Installer Grade Level Required: 01 O I I 0111 ON Page 1 of 3 _ CONSTRUCTIONForOffice'Use only AUTHORIZATION - "CDP File Number 100348-1 Davie County Health Department county ID Number 210 Hospital Street Evaluated For. REPAIR P.O.Box 848 Township: Mocksville NC 27028 PERMIT VALID UNTIL: Phone:336-753-6780 Fax:336-753-1680 0 1 / 1 4 / a 0 a 1 -Applicant: Jerry Blackwelder r perty Owner Jery Blackwelder Address: 159 Cedar Forest Lane dress: 159 Cedar Forest Lane 1 City: Mocksville City: Mocksville StatefLip: NC 27028 StatefZip: NC 27028 Phone#: Phone#: Property Location & Site Information rAddress/Road #: Subdivision: Cedar Forest Phase: Lot: 40 r Forest Lane e NC 27028 Directions Structure: SINGLE FAMILY hwy 158 left on Farmington Rd.to end tum right on Hwy 801,then right on Cedar Forest Lane #of Bedrooms: 3 #of People: "Water Supply: PUBLIC System Specifications Minimum Trench Depth: a 4 rDesign ssification: PmvisionaltySuitable Inches Minimum Soil Cover. 1 a e System? QYes QNo Inches low: 3 6 0 Maximum Trench Depth: 3 6 Inches Soil Application Rate: 0 a Maximum Soil Cover: a 4 Inches *System Classification/Description: *Distribution Type: GRAVITY-PARALLEL(eq.d-box) TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: Gallons *Proposed System: 25°�aREDUCTION 1-Piece: QYes QNo Pump Required:' ',QYes -a@No QMay Be Required' Nitrification Field 1 8 0 0 Sq.ft. PumpTank: Gallons No.Drain Lines 5 1-Piece:QYes QNo Total Trench Length: 4 5 0 ft. GPM vs— ft. TDH Trench Spacing: _ 9 Otnches O.C. Feet O.C. Dosing Volume: _ Gallons ® Trench Width: `'Inches 3 . Feet Grease Trap: Gallons Aggregate Depth: inches Pre-Treatment: ONSF OTS-1 OTS-11 Septic Tank InstallerGrade Level Required: 01 011 0111 OIV 1 CDP File Number 199348 - 1 County ID Number. -- ❑ Open Pump System Sheet Repair System Required:OYes. ®No ONo, buthas Available Space rDesign System Trench Spacing: IncAh inches 15A NCAC 18 ,1945 8 hes 0. . Classification: — Feet O.C. w: Feet ' Soil Application Rate: AggregateDepth: inches Minimum Trench Depth: *System Classification/Descri Inches ire pair Area Fxe it Inches' Maximum Trench Depth: *Proposed System: Inches Nitrification Field Sq. Maximum Soil Cover: Inches ft. No. Drain Lines *Distribution Type: Total Trench Length: ft. Pump Required: Oyes ONo OMay Be Required Pre Treatment: ONSF OTS-1 OTS-ll *Site Modifications No grading or constriction activity is allowed in areas designated for system and repair without approval of Health Department. *Permit Conditions The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder is responsible for checking with appropriate governing bodies in meeting their requirements. ; There isn't enough available space to a full repair.Istall as much system as space and setbacks allow. This Authorization forwastewater System Construction shall bevalid for a person equal to the period of validity of the Improvement Permit,not to exceed fiveyears,and may be issued atthe'sanetime the Improvement Permit issued(NCGS 130A-336(b)j If the installation has not been completed during the period of validity of the Construction P.r rmI%the information submitted In theapplicationfor a permit or Construction Authorization is found to have been Incorrect,falsified or changed,or the site is altered,the permit orConsiructlon Authorization shall become Invalid,and may be suspended or revoked(ANT(g)).;The person owning or controlling the system shall be responsible forassuring compliance. with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,reporting and repair (1938(b)). Applicant/Legal Reps. Signature Required? Oyes ONO Applicant/Legal Reps.Signature• Date:_ *Issued By: 2140-Nations,Robert Date of Issue: 0 1 / 1 4 / 2 0 1 6 Authorized State Agent: Malfunction Log Oyes r< *Hand Drawing Olmport Drawing **Site Plan/Drawing attached.** Page 2 of 3 E ON M E ENo M MMOEN M NONE CONSTRUCTION AUTHORIZATION ' Davie County Health Department 210 Hospital street CDP File Number: 199348" 1 P.O.Box 848 Mocksville NC 27028 County File Number: Date: .0 1 / 1 4 / 2016 Click below to Import an image from an external location: Drawing Type:Construction Authorization Davie COUNTY • L ^•• 210 Hospital Street P.O. Box 848 Mocksville NC 27028 TEL: 336-753-6780 FAX: 336-753-1680 Request ID: 62404 REQUEST FOR SERVICE/COMPLAINT INVESTIGATION REPORT REQUEST DATE: 01/05/2016 TAKEN BY: SECTION: N/A TYPE: PROPERTY NUMBER: 199348 ASSIGNED TO: Nations, Robert ESTABLISHMENT NUMBER: PERSON OR PREMISES TO SEE: OWNER: Jerry Blackwelder Jerry Blackwelder 159 Cedar Forest Lane 159 Cedar Forest Lane Mocksville , 27028 Mocksville NC, 27028 REQUESTED BY: McMahn Septic HOME: 336 248-6575 WORK: Cell: /�' Additional Information: �pr/�'�//�C /V ON 0 N f QS La S -�� La/lei CONDITION REPORTED:water coming out of end of tail lines COMMENTS: RECORD OF INVESTIGATION DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: DATE: HR/MT: COMMENTS EHS: EHS #: ACT CODE: Next Inspection Date: Status of Complaint: OPEN Resolved Date: Complaintant Contacted: NO DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR,rIMPROVEMENT PERMIT(REPAIR) I/� „yl n�han S i NAME P���ao AG GU'P.I(� e-C PHONE NUMBER I V`c�CO�'t � "'"��7�� ADDRESS (� ('PJC ¢? EYcC& l_ .l'1 SUBDIVISION NAME c���, . � (TV'5�6 0C c9709� LOT# 0 DIRECTIONS TO SITE DATE SYSTEM INSTALLED q`& 5 NAME SYSTEM INSTALLED UNDER TYPE FACILITY I—I NUMBER BEDROOMS NUMBER PEOPLE SERVED\)af'EfH:: TYPE WATER SUPPLY (/`;�,� SPECIFY PROBLEM OCCURRING -AUDde-ot OU-4 a, _ 'a'no,t I n(2 3 DATE REQUESTED I I l ab t �l�1NFORMATION TAKEN BY �� This is to certify that the information provided is correct to the best of my knowledge,and that I understand 1 am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1/93 /A �� {.:Permite's . DAVIE COUNTY'HEALTH DEPARTMENT —'��`'D 111 Name: Environmental Health Section P PERTY INFORMATION .t.,.� . P.O.Box 848 Directions to"property: L ti'a 7 ' � Mocksvihe;NC 27028 Subdivision Name: Phone#:336-751-8760 4/0 Section: Lot: AUTHORIZATION FOR WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION - — F _ AUTHORIZATION NO: 178 A Road Name: **NOTE**This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie Countv 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 wi A ice I 1 of G.S.Chapter 130A,.Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems) 1J ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION (7 IS VALID FOR A PERIOD OF FIVE YEARS. VIR !EN DA E ISUEDNf RESIDENTIAL SPECIFICATION:BUILDING TYPE S! #BEDROOMS�_#BATHS Z- #OCCUPANTS �- GARBAGE DISPOSAL:Yes or.No COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFT �r�#SEATS INDUSTRIAL WASTE:Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW(GPI �C/ NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. ! ' OTHER /� REQUIRED SITE MODIFICATIONS/CONDITIONS: f trw{Gl' 10, a�^ P�l0 L,J�-, ��A:-:�) �W` L I-Al, Etc- f IMPROVEMENT PERMIT LAYOUT LIL t **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 SYSTEM INSTALLED BY: ✓1>L V 1 az AUTHORIZATION NO._J� OPERATION PERMIT B • CAIS- DATE: **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THA T E SCRIBE ABO H S BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTE ,BUT SHALL IN NO WAY BETAKEN AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. y/ DQiD 07502(Revised) • O ,� L-1-71L DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION APPLICATION FOR IMPROVEMENT PERMIT(REPAIR) NAME_ As�oj PHONE NUMBER ADDRESS_ t Ce-DAQ �:OPxs I SUBDIVISION NAME i" `ej4sV ILIA; LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY- NUMBER BEDROOMS NUMBER PEOPLE SERVED TYPE WATER SUPPLY t SPECIFY PROBLEM OCCURRING DATE REQUESTED INFORMATION TAKEN B This is to certify that the information provided is correct to the best of my knowledge,and th/1uneratand I am responsible for all char es' carred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Rev.1193 _ DAVIE COUNTY HEALTH DEPARTMENT ` (Septic Tank) Improvements Permit and Certificate of Completion (Ground Absorption Sewage, Disposal System - G.S. Chapter,130-Article 13C) OWNER OR CONTRACTOR 0. 1 DATE 7 PERMIT LOCATION rC? ( g;,., , �, y 1611 S.R. NO. SUBDIVISION NAME !_� ��_ ,,�_ f rt ?:,t...z f LOT NO. SECTION OR BLOCK NO. HOUSE Er MOBILE HOME 0 BUSINESS '2---," House Trailer 800 Gal. 400 Sq. Ft. NO. BEDROOMS NO. BATHROOMS - Two Bedroom House 800 Gala 600 Sq. Ft. GARBAGE DISPOSAL UNIT YES ❑ NO [' — Three Bedroom House 900 Gal. 900 Sq. Ft. AUTO. DISHWASHER YES NO ❑ Four Bedroom House 1000 Gal. 1200 Sq. Ft. AUTO. WASH. MACHINE " YES Cil . NO ❑ SITE SUITABLE YES © NO [3 SIZE OF TANK gal. NITRIFICATION FIELD sq. ft. j , u DEPTH OF STONE IN LINES: / .. WATER SUPPLY: Individual ❑ Pnlili, f'/ d -r l IMPROVEMENTS PERMIT BY / /}.►�- � 'd'd7 INSTALLED BY CERTIFICATE OF COMPLETION By Date (8/16/73) *Construction must comply with all o her applicable State and local r g la ions LOT AREA -73 . o, I DAV I E COUNTY HEALTH DEPARTMENT P. 0. BOX 57 HOCKSVILLE, N. C. 27028 (704) 634-5985 Statement for Septic Tank Improvement Permits and/or Site Evaluations NAME A/. ,� �,.,�, DATE ISSUED,/? ADDRESS PERMIT NO. Explanation of charge /.� � .n�cs �1 pl�,zK� - Vie•/G/1 AMOUNT DUE 15.44) SANITARIAN PLEASE REMIT THE ABOVE AMOUNT ON RECEIPT OF THIS STATEMENT.