Loading...
209 Essex Farm Road Lot 141 f" Davie County, NC Tax Parcel Report Tuesday, December 20, 2016 pavt8 All data Is pmvided as taw outwernmty or guarantee of any Idnd ehherexpressed or Implied including but not gmhed to the Davie County, implied wamandesofmemhamxbnhyorghressfor apardcutaruse. Ali users ofDaAeCounty's GIS websheahalihadharm the %County of Davie, NoM Carolina, hs agents, cunsubanta, eordrae[ora cremployesa fmm any and all claims areauses of actlon due to cDUN�� NC or arising out of the use or inability to use the GS data provided by thiswwshe - ' WARNING: THIS IS NOT A SURVEY ` 215 -- ------216 F8030A0014 - Township: i NCPIN Number: 5870640565 Municipality: Account Number. 82521260 Census Tract: 37059-803 Listed Owner 1: r � 209 L i 209 ESSEX FARM ROAD Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAME COUNTY R -A State: IL Zoning Overlay: - ------ 204 ,---------- '-- 27006-0000 I No 201 LOT 14 ESSEX FARM PHASE 1 pavt8 All data Is pmvided as taw outwernmty or guarantee of any Idnd ehherexpressed or Implied including but not gmhed to the Davie County, implied wamandesofmemhamxbnhyorghressfor apardcutaruse. Ali users ofDaAeCounty's GIS websheahalihadharm the %County of Davie, NoM Carolina, hs agents, cunsubanta, eordrae[ora cremployesa fmm any and all claims areauses of actlon due to cDUN�� NC or arising out of the use or inability to use the GS data provided by thiswwshe - ' WARNING: THIS IS NOT A SURVEY ----Parcel Information Parcel Number. F8030A0014 - Township: Shady Grove NCPIN Number: 5870640565 Municipality: Account Number. 82521260 Census Tract: 37059-803 Listed Owner 1: MOORE MICHAEL R Voting Precinct: EAST SHADY GROVE Mailing Address 1: 209 ESSEX FARM ROAD Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAME COUNTY R -A State: NC Zoning Overlay: Zip Code: 27006-0000 Voluntary Ag. District: No Legal Description: LOT 14 ESSEX FARM PHASE 1 Fire Response District ADVANCE Assessed Acreage: 0.69 Elementary School Zone: SHADY GROVE Deed Data: 10/2009 Middle School Zone: WILLIAM ELLIS Deed Book / Page: 008100229 Soil Types: GnB2 Plat Book: 0009 Flood Zone: Plat Page: 290 Watershed Overlay: DAVIE COUNTY Building Value: Outbuilding & Extra Freatures Value: Land Value: Total Market Value: Total Assessed Value: pavt8 All data Is pmvided as taw outwernmty or guarantee of any Idnd ehherexpressed or Implied including but not gmhed to the Davie County, implied wamandesofmemhamxbnhyorghressfor apardcutaruse. Ali users ofDaAeCounty's GIS websheahalihadharm the %County of Davie, NoM Carolina, hs agents, cunsubanta, eordrae[ora cremployesa fmm any and all claims areauses of actlon due to cDUN�� NC or arising out of the use or inability to use the GS data provided by thiswwshe - ' M Davie County Health Department. 1 �P 6IEnvironmental. Health Section .'P.O.`Box 848 O s, 210 Hospital Street O U 14 C Courier # : 09-40-06 1911 Mocksville, NC 27028 Phone: (336) - 753 - 6780 ON-SITE WASTEWATER CERTIFICATION Fax: (336) - 75&1680, . /J�% / (Check One) /Replacement Remodeling Reconnection Name: /'// �^"—,-/W • C/.,Y, /P Il✓ Phone Number � �9 37d 3 (Home) Mailing Address: -2-./A< /)75/ 10 %ZeQ (Work) 4 ilIC-/-V 1110 A/P .2701I Email Address:, i&,i Detailed Directions To Site: c �,le r Ae Gill Please Fill In The Following Information Name System Installed Under: 4110114 W1, Date System Installed (Month/Date/Year): Is The Facility Currently Vacant? Yes No Any Known Problems? Yes N� If Yes,: Please Fill In The Type Of Facility:_ t About The EX7iSNG Facility: A S Type Off Facility:y f �Number Of Bedrooms:__4­Number Of People: If Yes, For How Long? t v Information About The NEW Facility: Number Of Bedrooms: / Number of People. i Date Requested: For Environmental Health Office Use Only pprove Disapproved ents: Environmental Health Specialist( xly�O"f/, Date:'W *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) thatthe on-site wastewater system will function properly for any given period of time. ` Payment Cash Check M/��ney/O�rder # , Amount:$ 0. Date: Z 3 Paid By: LL JVI (il (a/y}� 1%p % (11(N Received By n, n, . , Account #: 3V%2 - Invoice /) 7l ?j { Environmental Health Specialist( xly�O"f/, Date:'W *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) thatthe on-site wastewater system will function properly for any given period of time. ` Payment Cash Check M/��ney/O�rder # , Amount:$ 0. Date: Z 3 Paid By: LL JVI (il (a/y}� 1%p % (11(N Received By n, n, . , Account #: 3V%2 - Invoice /) 7l ?j y 1 . o Za -ts x-30 -0 NO0 Appraisal Card DAVIE COUNTY NC Page 1 of 1 L 3/27/2013 3:48:40 PM OGRE M[CNAEL R MOORE MICHELLE M Ratum/Appeal Notes: FS -030 -AO -014 09 ESSEX FARM RD -- UNIQ ID 9586 2521260 SWIM -4-114034 ID NO: 5870690565 ' COUNTY TAX (100), FIRE TAX(100) _ GRD NO.1 oft oval Year: 2013 Tax Year: 2013 LOT 14 ESSEX FARM PHASE 1 1.000 LT SRC= DOpedlon ,ppmls b 19 On 10/14/2008 07WZ MOCI(S CHURCH - TW -07' -C- EX -AT- LASTACTION20120521 CONSTRUCTION DETAIL MARKET VALUE - DEPRECIATION CORRELATION OF VALUE oun0abon-3 StandaN 0.050 - %- ntlnuwsFooOn 5.0 Efl. UA BASE RATE RCN EYB AYB - EDENCE TO MARKET S MO ub Floor System -4 Area 300] 132 192.4012]964 2008200 %GO00 1 95.0 YEPR. BUILDING VALUE -GRD 2656 I ootl B.0 01 101 or Walk -10 - TYPE: Single Family ReNEenlWl Single Family Re514er,0El EPR-OB/XF VALUE -GRD - 28,98 'mum/Vnyl Siding 31AK qARKET LAND VALUE -GRD 9,0 ix a Oar Walls -21 STORIES: 2-1.55MM. - OTALMARKETVALUE-GRD 351,64 0( ax Br& 0. - -. W E G OTAL APPRAISED VA -RD 351,61 go" g Structure -03 able8. OTAL APPRAISED VALUE -PARCEL 351,64 ooflng Cover -10 - OTAL PRESENT USE VALUE -PARCEL ooEShinIe3105hi le 6.0 - '- Merlor Wall Construction - 5 - -. OTAL VALUE DEFERRED -PARCEL all/Sheetrock 26.0 - - OTALTAXABLE VALUE -PARCEL 351,64 ramlor Wall C4 4uGlon-6 PRIOR mstom intelor M +--24--+ - SUILDING VAWE, - 295,52 nte0or Floor Cover -12 - - 1 I anlwoo0 10.0c 2 1 - BXFVALUE 24,41 nterllr Floor Cover -14 +9-� 6 _ MD VALUE 57,00 �arpet 0.0 IFUS+-14-++, - ENT USE VALUE ea0ng Fuel -04 - 6 ++FOG I EFERRED VALUE + I S + I I IecWc 1.0 - 1 3 OTALVALUE - 37693 eating Typ, - SO 2 2 , eat Pump 4.Ou 4 1 - - fConElOonin9Type -03 - 1 1 _ _ PERMIT ntrsl - 4. +-14-+ CODE I DATE I NOTE NUMBER AMOUNT rooma/Bathr0oma/Half-Bathrooms - /30 16.00 OUT: WTRSHD: - rooms - SALES DATA AS-2FU5-2LL-0 - 114-1 FF- INDICATE th trams O W O D O - +--23--+++++-SB-+ D ATE DEED SALES -ILL-ILL-0 IBA 5 I ;E M. - 1 2 OpK PAGE R TYPE PRICE - 1 2 - - 810 229 10 WD Q 1 3350 DIAL POINT VALUE 1119.TDC 3 1 0748 393 2 00 WD Q V 570 - 2 2 - - # )9)1046 6 00 TD P I 25500 BUILD]NG ADJUSTMENTS I I F G D ] )13 818 5 00 % V moll 9 ABAVG LIDO I 1 I Deni 9 FA 1.050 I +11+ 3 iza 3 Sire 0.880 +11+ T 1 - 1- To Sire OTALADJUSIatENTFACTOR 1.11+I1-+ 1 I '. +FOP22-+ I - - HEATED AREA 2,735 OTALQUALTYINDU 13 +12+ + NOTES Il-1SX36INGO POOL SUBAREA UNIT ORIG% ANN DEP % OB/XF DEPR. TYPE GS AREA %RPL CS ODE DESCRIPTIO LT NIT 'PRICE GOND LDG B AYB EYB RATE V CORD VALUE 1)0 1 15)35 L/VINYL 1 3 69 31.8 _ _ 011 01 5 9 1854 GO 69 W 2901 NCE METpI 1] 22.4 - _ _ 03 O1 9 350 OG 44 OB 352 30 ON PAVING 11 2 2 20 3.5 011 011 S 9 693 OTALOS/XFVALUE - 2897 OF 16 03 535 5 509 4860 DD 12 O2 231 - - -Prete! REPLACE .2 1'B- UOAREA OTALS UILDING DIMENSIONS BAS-W25537E11S3 FOP=54E22NIIWIIS7WI13 Ell N7E11 FGD=N11E22531W252WBN2W12N203 N13E22N22 W18 WDD=NlOW1451DHN3E553E35 3N3W353W6PTR-N30 FOG=N32 FUS-E4N16W24512W9516EIIN4E4 N8E34 W14532E1/ 5303. LAND INFORMATION 16MESTTNER ADJUSTMENTS TOTAL NO BEST DBE LOCAL —N- DEPTH/ WD CORD NO NOTES O LANDUNIT LAND UNT TOTAL ADJUSTED LAND LAND SE CODE ZONING TAG! EPT SIIE MOD FAR RF AC LC TO OT TYPE PRICE UNITS TYP ADJSf UNITPRICE VALUE NOTES FR RES 03011 0 1 57,00- QI DO LT 1 1.00 57,000.00 5]00 DIAL MARKET LAND DATA - 57,0001 DIAL PRESENT USE DATA - http://maps.co.davie.ne.us/ITSNet/AppraisalCard.aspx?parcel=F803OA0014 3/27/2013 a- • _ DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 w (336)751-8760 Fax # (336)751-8786 ' t Account #: 990002260 OPERATION PERfaxT PIN/EH #:. 5870-64-2265.14 - w Billed To: Allen Wayne Builders,LLC. Subdivision Info: Essex Farm Lot # 14 t Reference Name: Location/Address: Essex Farm Rd -27006 l Proposed Facility: Residence Property Size: 0.691 t , ATC Number: 4858 t f3 **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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 will function satisfactorily for any given period of time. '( . System Type: S.TsMandacturezi Tank Date Tank Size Pump Tank Siz- fvs�Z© System Installed By: r /gyp r SYS E.H. Specialist:` Ly et, :r to yF � T (' o/n a- z-ty r '{YA1% �~ DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751=8760 Fax # (336)751-8786 AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION Account M 990002260 Billed To: Allen Wayne Builders,LLC. Reference Name: Proposed Facility: Residence ATC Number: 4858 Tax PIN/EH M 5870-64-2265.14 Subdivision Info: Essex Farm Lot # 14 Location/Address: Essex Farm Rd -27006 Property Size: 0.691 Site Type: RN0./ew ❑Repair DExpansion **NOTE** This Authorization to Construct (ATC) MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any building permit(s), (in compliance with Article 11 of G.S. Chapter 130A Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems). THIS AUTHORIZATION TO CONSTRUCT IS VALID FOR A PERIOD OF FIVE YEARS. This ATC is subject to revocation if site plans, plat or the intended use change. - - Residential Specifications: # Bedrooms `f # Bathrooms # People_ BasementO Basement plumbingO Non -Residential Specifications: Facility Type # People_ # Seats_ Square Footage(or Dimensions of Facility) Lot Size #01 ofXr; Type of Water Supply: ❑County/City OWell ❑CommunityWell System Specifications: Design Wastewater Flow (GPD) 4 �Tank Size 1000 GAL. Pumn Tank ► OUDGAL. pp u u 1 -'� 0 Trench Width �D _M��ax. Trench Depth ? �o Rock Depth ' W A _ Linear Ft. r 4 6C =Qp J_Crsk DV Site Modifications/Conditions/Other: ��Zl )O Ji�OY0 Yi+1 ��V\e 10.V14 vy�US� VA-NA\Y�\ A\AkM 04- 11tS�• �v�s1��1 ©1n cgv�loin Awn •ko S� UaSL.�ao)C_.. uSk IA!g 2S' - CA ---ori Contact the Davie County Environmental Health Section for final inspection of this system between -5 -lc V -r - . R30 _ 930a_m_ nn the day of inatallatinn. Telenhone #!3361751-8760. - - (o l inec I I'% VQo� v41s' Tal -0 41bd ocaz'A o7 N - ail M n ? 17 Environmental Health S DCHD 11/06 (Revised) SITE EVALUATION/IMPROVEMENT PERMIT & ATC U' Davie County Environmental Health 6 200a . P.O. Box 848/210 Hospital Street MAy. Mocksville,NC 27028 „xH (336)751-8760/Fax(336)751-8786 2Waluation/Improvement Permit Authorization To Construct(ATC) O Both ONew System ORepair to Existing Sys em OExpansion/Modification of Existing System or Facility ***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions. I:W VI IMMI_I Name to be Billed A4:0 P / S Contact Person Te Billing Address P. D. Ae x 12 to Home Phone City/State/ZIP Clemmo ,S, A).(— 27o12 Business Phone 39q Name on Permit/ATC if Different than Above. Address PROPERTY INFORMATION *Date House/Facility Corners Flagged 5 It D g NOTE: A survey plat or site plan must accompany this application., Included: O Site Plan DPlat(to scale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Owner's Owner's Property Address_ Lot Size Subdivision Name(if Directions To Site: , Tax PIN# SB70 -(7 On Phone Number _City/State/Zip &0e-ksL1.'Ilo- _City If the answer to any of the following questions is "yes", supporting documentation must be attached. Are there any existing wastewater systems on the site? DYe4No Does the site contain jurisdictional wetlands? DYeso Are there any easements or right-of-ways on the site? CYes rwo Is the site subject to approval by another public agency? DYes NNo Will wastewater other than domestic sewage be generated? DYes kNo IF RESIDENCE FILL OUT THE BOX BELOW # People--- . — # Bedrooms # Bathrooms 2 . S Garden Tub/Whirlpool XYes ONo Basement. DYeNBasement Plumbing: DYes ONo IF NON -RESIDENCE FILL OUT THE BOX BELOW Type of Facility/Business Total Square Footage of Building # People # Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats Type system requested:. Conventional OAccepted Ohmovative ❑Alternative ❑Other Water Supply Type: G County/City Water D New Well ❑Existing Well ❑ Community Well r Do you anticipate additions or expansions of the facility this system is intended to serve? D Yes If yes, what type? 0 This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension br revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating and flagging or stakingAe house/facility location; proposed well location and the location of any other amenities. Site Revisit Charge Pr is oro ne� gal representative signature Date(s):— ©� Client Notification Date: Al w. EHS: Date --- I . Sign given DYes 0No Account # Revised 11/06 Invoice # X. OG 2 g 2001 V FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC Davie County Environmental Health .' P.O. Box 848/210 Hospital Street Mocksville, NC 27028 - (336)751-8760/Fax(336)751-8786 uation/Inrprovement Permit D Authorization To Construct(ATC) D Both System ❑Repair to Existing System DExpansion/Modification of Existing System or Facility APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED IDED. Refer to the INFORMATION BULLETIN for instructions. APPLICANT INFORMATION Name to be Billed -ASC /0c Va6.pnrAr mat_, nuc- Contact Person - 72,P fAy &,r;m dX Billing Address A-6 -A X 3f0 Home Phone City/State/ZIP �+O 270Z t3 - Business Phone 7S/ - 780a - r Name on Pennit/ATC if Different than Above Mailing Address City/State/Zip rrcvrarcr r uvrvrcrvrrrllvry 'care nuusuravurr i.urucra rra cu NOTE: A survey plat or site plan must accompany this application Included: D Site Plan IaQ[oscale) (Permit is valid for 60 months with site plan, no expiration with complete plat.) Property Lot Sin If the answer to any of the following §uwtiomlis `yes", supporting documentatioryry must be arched. Are there any existing wastewater systems on the site? DYes - - Does the site containjurisdictional wetlands? DYes ONo Are there any easements or righto€ways on the site? D'i'es 01jo . Is the site subject to approval by another public agency?. DYes TNIpG - Will wastewater other than domestic sewage be generated? OYes RNo IF RESIDENCE FILL OUT THE BOX BELOW #People #Bedrooms- !f #Bathrooms Garden Tub/Whirlpool DYes UNo Basement: -DYes ONo Basement Plumbine: DYes ONo T NON -RESIDENCE FILL OUT THE BOX BELOW rype of Facility/Business - Total Square Footage of Building # People Y Sinks # Commodes # Showers # Urinals Estimated Water Usage (gallons per day) - (Attach documentation of similar facility water consumption) FOODSERVICE ONLY: # Seats - Type system requested: 176onventional DAccepted OInnovative OAltemative OOther i � _ - Water Supply Type: O'County/City Water O New Well DExisting Well O Community Well Do you anticipate additions or expansions of the facility this system is intended to serve? 0 Yes D No If yes, what type? This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use changes, or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable . laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and locating an agging or staking the houselfaciliry location, proposed well location and the location of any other amenities._ - - - - Site Revisit Charge Property r s or o er's legal represents re - Date(s): Client Notification Date: 'Date EHS: Sign given DYes ONo Account # Revised 11/06 - - Invoice# yr ''� • DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation APPLICANT INFORMATION PROPERTY INFORMATION Account #: 990004425 Tax PIN/EH #: 58715 $2b i4= Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm Lot # 14 Reference Name: Brad Coe Location/Address: Cornatzer Rd -27006 / Proposed Facility: Residence Property Size: 0.691 Ac. Date Evaluated: — 0)0 '6 f Water Supply: Evaluation By: On -Site Well Auger Boring Community Pit Public Cut FACTORS 134 12 P P 4 5 6 7 Landsca 'e position j Slope % HORIZON I DEPTH _ Texture group C C Consistence. ;t C Pn Structure Mineralogy p . •P i •HORIZON H DEPTH. I - _ Texture group C, 53 'Consistence' P, r -Pr 41 Structure ISA K 519k S k Mineralogy HORIZON III DEPTH Texture'groupF L Consistence JVP 0: Structure - Mindralogy,- _ HORIZON IV DEPTH Texture group Consistence Structure Mineralogy- - - SOIL WETNESS RESTRICTIVE HORIZON' -SAPROLITE L17—&l CLASSIFICATION LONG-TERM ACCEPTANCE RATE _ 7i),,r ' SITE CLASSIFICATION: S4 a b` e EVALUATION BY: !Cn ab A lay b vl 5_ LONG-TERM ACCEPTANCE RATE: OTHERS) PRESENT: REMARKS: LEGEND - Landscape Positron - 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 p. LS - Loamy sand SL - Sandy loam L - Loam SI - Silt SICL - Srlty'clay loam- SIL - Silty loam CL - Clay loam SCL - Sandy clay loam' SC - Sandy clay SIC - Siltyclay C - Clay CONSISTENCE Moi -t V FR -Very friable FR - Friable FI - Firm VFI Very firm EFI - Extremely firm 33sI 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 Mh=aloev 1:1, 2:1, Mixed 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 f Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LIAR Long-term acceptance rate - gal/day/ft2 DCiIO OS/115 (Revised) 'A i i Davie County Environmental. Health P.O. Boz 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760/ Fax (336)751-8786 Account #: 990004425 IMPROVEMENT PElZ&AfIN/EH #: 5870-64-2265.14 Billed To: PSC Development Corp. Inc. Subdivision Info: Essex Farm. Lot # 14 Address: PO Box 340 Location/Address: Comatzer Rd -27006 City: Mocksville Property Size: 0.691 acre Reference Name: Brad Coe Proposed Facility: Residence **NOTE**This Improvement Permit DOES NOT authorize the construction of a wastewater system. An Authorization.To Construct a wastewater system, must be obtained from this office prior to the construction/installation of a wastewater system or the issuance of a building permit(in compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems). This Improvement Permit is subject to revocation.if site plans, plat or the intended use change. Pe[mitType: 016 ❑Repair. ❑Expansion Permit Valid for: 8<Years DNo Expiration- Residential Specifications: #Bedrooms#Bathrooms_#People_ BasemeatD Basement plumbingo Non -Residential Specifications: Facility Type # People_ # Seats_ Square Footage(or Dimensions of Facility) Design Flow(GPD): 430 Type of Water Supply: l9County/City ❑ Well ❑ Community well As stated in 15A NCAC18A.1969'5) Site Modifications/PermitConditions. accelsted Systems may also be used /� System Type LTAR Initial IA CG G OT��P 0 5 - Repair C4 cc r oy ed I O • a 5- �Nr llv ��QA1� 301 )L 40 y$D o 100 t 9rU4�j`L is M4 of / Eavironinental Health Specialist Date (� ^ is - 0 7 DAVIE COUNTY ENVIRONMENTAL HEALTH P.O. Box 848/210 Hospital Street Mocksville, NC 27028 (336)751-8760 Fax # (336)751-8786 Account M 990002260 Billed To: Allen Wayne Builders,LLC. Reference Name: Proposed Facility: Residence ATC Number: 4858 'OPERATION PER"%x PIN/EH #: 5870-64-2265.14 Subdivision Info: Essex Farm Lot # 14 Location/Address: Essex Farm Rd -27006 Property Size: 0.691 t '7 13. **NOTE** The issuance of this Operation Permit shall indicate the system described on the ATC 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 will function satisfactorily for any given period of time. - O System Type: S.T. ManufacturexO U Tank Date Tank Sizer/ 4 G Pump Tank Size 5 System Installed By: ,r, OLE t E.H. Specialist: o Phone: (336) - 753 - 6780 .Davie Codnty Health,Department Environmental nmental Health Section P.O. Box 848 210 Hospital Street our ser tt : J -'kV -VU Mocksville, NC 27028 ON-SITE WASTEWATER, CERTIFICATION FOR DWELLING (Check One) Renlacement Remodeling Reconnection Pax: (336) - 753-1680 Name: �T6 i;, rn Phone Number (Home) Mailing Address: 71 An-;":�K7 9-36 (Work) c- u r 6 2 Ot ZFX Detailed Directions To Site: ce 2n, 4'. E_5S Property Address: a w co -r %W Please Fill In The Following Information About Th..e E)17STING Facility: Name System Installed Under. /AI dA I1 "1 '9 1 `Type Of Facility K Date System Installed (Month/Date/Year)--- Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes1-0 If Yes, For How LonLong16 Any Known Problems? YesC0Ies, Explain: 1)f Y Please Fill In The Following Ififoerhation About The NEW Facility: Type. Of Facility: 4/ Number Of Bedrooms-�Number of People Tool Size: L6 /r 3& Garage Size: - Other. )klauested By: nate Requested: 312511,.? (Signature) For Environmental Health Office We Only Disapproved 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(�heck I Money 0 _k rder qj/, 7q Amount:$ U Date: Paid By:Received By: t7 Wr' (1117 Account #: Invoice 9:q(v (0 -2,