160 Hickory Tree Road Lot 15Davie County, NC Tax Parcel Report Thursday, January 12, 2017
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage:
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
Land Value:
Total Assessed Value:
WARNING: '1111515 NOTA SURVEY
Parcel Information
J7010A0015
Township:
Fulton
5768235000
Municipality:
82530375
Census Tract:
37059-804
HOPE HOMES OF DAVIE COUNTY INC
Voting Precinct:
FULTON
C/O BETHLEHEM UMC
Planning Jurisdiction:
Davie County
ADVANCE
Zoning Class: DAVIE COUNTY R-20
NC
Zoning Overlay:
27006-0000
Voluntary Ag. District:
No
LOT 15 HICKORY TREE SECTION ONE
Fire Response District:
FORK
0.45
Elementary School Zone:
CORNATZER
8/2015
Middle School Zone:
WILLIAM ELLIS
009970959
Soil Types:
GnB2
0004
Flood Zone:
170
Watershed Overlay:
DAVIE COUNTY
Outbuilding & Extra
Freatures Value:
Total Market Value:
9 �'mi�A All data is provided as is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the
Davie County, implied warranties of merchantability or fitness for a particular use. All users of Davie County's GIS webahe shall hold harmless the
�T/-r County of Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to
r'O tl x�4 1\ C or arising out of the use or Inability to use the GIS data provided by this website.
it.
OPERATION PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753.1680
Applicant: Hope Homes of Davie County
Address: 321 Redland Road
City: Advance
State2ip: NC 27006
Phone #: (336) 909-2910
Address/Road #:
Hickory Tree Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
*Water Supply: PUBLIC
*IP Issued by, 2140 -Nations, Robert
*CA issued by: 2140 - Nations, Robert
Design Flow: 3 6 0
Soil Application Rate: 0 3
Nitrification Field
No. Drain Lines
Total Trench Length:
Trench Spacing:
Trench Width:
Aggregate Depth:
*CDP File Number 228407-1
5768235400
County ID Number.
Evaluated For, NEW
Township:
/ Property owner: Hope Homes of Davie County
Address: 321 Redland Road
City: Advance
State/Zip: NC 27006
\ Phone #: (336) 909-2910 _
ierty Location & Site Information
Subdivision: HickoryTree Phase: Lot: 15
Directions
Hwy 64 East, right on No Creek Rd. On left Hickory
Tree Rd
*System Classification/Description:
TYPE 11 A CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS)
SaproliteSystem? OYes RNo
*Dist ributionType: GRAVITY -SERIAL Pump Required?
OYes (Mo
*Pre Treatment:
Drain fiel
1 2 0 0 Sq. It,
5
3 0 0 ft.
9 ()Inches
t O.C.
C.
— 3 �Fe eIncht
inches
Minimum Trench Depth: 3 6
Minimum Soil Cover. a 4
Maximum Trench Depth: 3 6
Maximum Soil Cover: a 4
*System Type: INFILTRATOR QUICK 4 STANDARD
Installer: Randy Miller
Certification #: 1128
*ENS: 2140 -Nations. Robert
Date: 0 9/ 0 9/.1 0 1 6
Inches
Inches � Approval Status
Inches pproved O Disapproved
Inches
CDP Fite Number 228407 - 1
Manufacturer. Shoaf
STB: 760
Gallons:
1000
Supply Line
Date:
Date:
0
6/
1 4
/.2 0 1 6
*Filter Brand:
POLYLOK PL -122 With Pipe Adapter
ST Marker.
❑
Yes
❑
No
einforced Tank:
❑
Yes
No
No
1 Piece Tank:
❑
Yes
El
No
County ID Number: 5768235000 1 R
Lat.
Long:
Installer: Randy Miner
Certification #: 1128
*EH S: 2140 -Nations, Robert
Date: 0 9/ 0 9/ 2 0 1 6
Approval Status
®Approved ❑ Disapproved -
Pump Tank
Manufacturer, installer
PT: Certification #:
Gallons:
Supply Line
Date:
Date:
inch diameter
Installer.
RiserSealed ❑
Yes
❑
No
RiserHeight: ❑
Yes
❑
NO (Min.6 in.)
nforced Tank: ❑
Yes
❑
No
1 Piece Tank: ❑
Yes
❑
No
*EH S:
Date:
Approval Status
Approved ❑ Disapproved
Pump Type:
Installer.
Dosing Volume: — Gal Certification #:
Draw Down: Inches *ENS:
*Chau:
Supply Line
Date:
Pie Size:
inch diameter
Installer.
Pipe Length:
feet
Certification #:
*Schedule:
❑
*EHS:
Approval, Status:,
Pressure Rated ❑ Yes
❑ No
Date:
/
Wroved fittings ❑ Yes
❑ NOApproval
No
Status
Approved ❑ Disapproved
� I
Pump Type:
Installer.
Dosing Volume: — Gal Certification #:
Draw Down: Inches *ENS:
*Chau:
Date:
Valves Accessible ❑ Yes
❑
No
Flow Adjustment Valve ❑ Yes
❑
No
Check -valve ❑ Yes
❑
No
Approval, Status:,
PVC unions p Yes
❑
No
❑ Approved C7 Disapproved
Vent Hole ❑Yes
❑
No
Anti -siphon Hole [Q Yes ❑ No
9 CDP File Number 228407 -1
NEMA 4X Box or Equivalent
Box 12 inches Above Grade
Box Adj. To Pump Tank
Conduit Sealed
Pump Manually Operable
*Activation Method:
Alarm Audible
Alarm Visible
County ID Number: 5768235000
❑ Yes ❑ No
❑ Yes ❑ No
2140 - Nations, Robert
*Operation Permit completed by:
Authorized State Age
Owner/Applicant Signature:
Approval Status
Approved disapproved
Date of Issue: 0 9/ 0 9/ x 0 1 6
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 IIk sewage septic system.
Rule .1961 requires that a Type TY'E II A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: NIA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator: NIA
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 entitywith a certified operator or 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 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 ownerand 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.**
Electric Equipment
❑
Yes
❑
No
Installer.
❑
Yes
❑
No
Certification #:
❑
Yes
❑
No
❑
Yes
❑
No
*EH S:
❑
Yes
❑
No
Date:
❑ Yes ❑ No
❑ Yes ❑ No
2140 - Nations, Robert
*Operation Permit completed by:
Authorized State Age
Owner/Applicant Signature:
Approval Status
Approved disapproved
Date of Issue: 0 9/ 0 9/ x 0 1 6
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 IIk sewage septic system.
Rule .1961 requires that a Type TY'E II A. septic system meet the following criteria:
Minimum System Review By The Local Health Department: NIA
Management Entity: OWNER
Minimum System Inspection/Maintenance Frequency By Certified Operator:
NIA
Reporting Frequency By Certified Operator: NIA
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 entitywith a certified operator or 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 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 ownerand 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
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Drawing Type: Operation Permit
CDP File Number: 228401' 1 1
County File Number: 5768235400
Date: /./..
Olnch
Scale: OBlock
O N/A
T
'
k
17-17-7
--F—!
LI—jJ
J i I
i
I
I I
7-1?t
�..._�___.
1
Lt7-r
=� I I I
I s�
r
i ----
i
I
!
v
t 1 !
l I 1
-
i71
f
CONSTRUCTION
AUTHORIZATION
Davie County Health Department
t< 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: Hope Homes of Davie County
Address: 321 Redland Road
City: Advance
State/Zip: NC 27006
Phone #: (336) 909-2910
For Office Use Only
"CDP File Number 228407 - 1
County ID Number: 5768235000
Evaluated For: NEW
�, Township:
0 7/ 1 8/ a 0 a 1
Property Owner: Hope Homes of Davie County
Address: 321 Redland Road
City: Advance
State/Zip: NC 27006
Phone #: (336) 909-2910
Property Location & Site Information
Address/Road #:
Hickory Tree Rd
Mocksville NC 27028
Structure`. SINGLE FAMILY
# of Bedrooms: 3
# of People:
`Water Supply: PUBLIC
Subdivision: Hickory Tree
Phase: Lot: 15
Directions
Hwy 64 East, right on No Creek Rd. On left Hickory Tree
Rd
Classification:
Provisionally suitable
Minimum Trench Depth:
a 4 Inches
\Site
Saprolite System?
O Yes _ ® No
Minimum Soil Cover:
1 a Inches
Design Flow:
3 6 0
Maximum Trench Depth:
3 6 Inches
Soil Application Rate:
0 3
Maximum Soil Cover:
a 4 Inches
"System Classification/Description:
"Distribution Type:
GRAVITY - SERIAL
TYPE It A. CONV SYSTEM (SINGLE-FAMILY
OR 480 GPD OR LESS) Septic Tank:
1 0 0 0
Gallons
"Proposed System: 25% REDUCTION
1 -Piece:
O Yes ®No
Pump Required: O Yes
® No O May Be Required
Nitrification Field
1 a
0
0 Sq. ft.
Pump Tank:
Gallons
No. Drain Lines
4
1 -Piece:
OYes 0 N
Total Trench Length:
3 0 0
GPM --vs-- ft. TDH
ft
Trench Spacing:
_
9
® O Inches O.C.
Feet O.C.
Dosing Volume:
Gallons
Trench Width:
3
R Inches
Feet
_
Grease Trap:
Gallons
Aggregate Depth:
inches Pre -Treatment: O NSF OTS -1 OTS -11 /
Septic Tank Installer Grade Level Required: 01011 O 111 01V
Page 1 of 3
CDP File Number 228407 - 1
*Site Classification:
Design Flow:
Provisionally Suitable
County ID Number: 5768235000
red:®Yes O No ONO, but has Available
Soil Application Rate: 0 - 3
*System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25% REDUCTION
Nitrification Field
1
a 0 0 Sq. ft.
No. Drain Lines
4
_ 3O Inches
® Feet
Total Trench Length:
13
0
0 ft.
❑ Open Pump System Sheet
Trench Spacing:
_ 9 O Inches O.,
® Feet O.C.
Trench Width:
_ 3O Inches
® Feet
Aggregate Depth:
inches
Minimum Trench Depth:
D
4
Inches
Minimum Soil Cover:
1
a
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
D
4
Inches
*Distribution Type:
GRAVITY - SERIAL
Pump Required: Oyes ®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. Rma s
750
*Permit Conditions
The issuance of this permit bylthe 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. R.w
aining
2000
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 (.1937(8)). 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 7 1 8 / 0 1 6
Authorized State Agent: Malfunction Log O Yes
® Hand Drawing O Import Drawing
**Site Plan/Drawing attached.**
Page 2of3
Click below to import an in
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street CDP File Number:
P.O. Box 848 5768235000
Mocksville NC
County File Number:
4 —1 (IP Date: AT/ 18 a 0 16
i ge from n external location: Drawing Type: Construction Authorization
Page 3of3
P1 P2
CONSTRUCTION For Office Use Only
AUTHORIZATION "CDP File Number 228407-1
= Davie County Health Department County ID Number: 5768235000
210 Hospital Street EMAILED Evaluated For: NEW
P.O. Box 848 I�bl �lY ' r Township:
Mocksville PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax: 336-753-1680 0 7/ 1 8/ a 0 a 1
Applicant: Hope Homes of Davie CountyProperty Owner: Hope Homes of Davie County
Address: 321 Redland Road Address: 321 Redland Road
City: Advance City: Advance
StatefZip: NC 27006 StatefZip: NC 27006
Phone #: (336) 909-2910 Phone #: (336) 909-2910
Property Location & Site Information
Address/Road #:
Hickory Tree Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
'Water Supply: PUBLIC
Subdivision: HickoryTree
Phase: Lot: 15
Directions
Hwy 64 East, right on No Creek Rd. On left Hickory Tree
Rd
'rSite Classification: Provisionally suitable
Saprolite System? QYes (QNo
Design Flow: 3 6 0
Soil Application Rate: 0 3
*System Classification/Description:
I Y OR 480 GPD OR LESS
<7
Minimum Trench Depth:
a
4
Inches
Minimum Soil Cover.
1
a
Inches
Maximum Trench Depth:
3
6
Inches
Maximum Soil Cover:
a
4
Inches
*Distribution Type: GRAVITY - SERIAL
TYPE II A. CONY SYSTEM (SINGLE -FAM L � Septic Tank:
1 0 0 0 Gallons
.f
*Proposed System: 25% REDUCTION 1 -Piece: Oyes @No
Pump Required: QYes ®No OMay Be Required
Nitrification Field 1 a 0 0
Sq. ft. Pump Tank: Gallons
No. Drain Lines 4 1 -Piece: QYes ONo
Total Trench Length: 3 0 0 ftGPM—vs— ft. TDH
Trench Spacing: — 9 0Inches O.C• Dosing Volume: _ Gallons
0 Feet O.C.
Trench Width:_ 3 @Inches
O Feet Grease Trap: Gallons
Aggregate Depth:
inches Pre Treatment: ONSF OTS -1 OTS -II /
Septic Tank Installer Grade Level Required: 01 011 OIII OIV
Donn 4 nf'2
CDP File Number 228407 -1
County ID Number: 5768235000
❑ Open Pump System Sheet
Repair System Required: OYes ONO .ONO, but has Available Space
/Repair System Trench Spacing: 9 Inches 0."
*Site Classification: Provisionally Suitable — Feet O.C.
Trench Width: 0 Inches
Design Flow: 3 6 0 — 3 Feet
Soil Application Rate: 0 3 Aggregate Depth: inches
Minimum Trench Depth: a 4
*System Classification/Description:
TYPE 11 A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR LESS, Minimum Soil Cover. 1 a
'Proposed System: 25% REDUCTION
Nitrification Field 1 x 0 0
Sq. ft.
No. Drain Lines 4
Total Trench Length: 3 0 0
Maximum Trench Depth: 3 6
Maximum Soil Cover. a 4
*Distribution Type: GRAVITY -SERIAL
Inches
Inches
Inches
Inches
Pump Required: OYes QNo OMay Be Required
Pre Treatment: ONSF OTS -1 OTS -II
"Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
I
"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. ;
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 maybe 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 (.1937(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? Oyes ONO
Applicant/Legal Reps. Signature: Date: I I
*Issued By: 2140 -Nations, Robert �4z Date of Issue: 0 7/ 1 8 1 a 0 1 6
Authorized State Agent:
Malfunction Log OYes
01 -land Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
F0
CONSTRUCTION AUTHORIZATION
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Drawing Type: Construction Authorization
CDP File Number:
County File Number: 5768235000
Date: 0 7/ 1 8 1 2 0 1 6
0 Inch
Scale:
OBlock
ON/A
"I
CONSTRUCTION AUTHORIZATION
Davie County Health Department '
210 Hospital Street CDP File Number:
P.O. Box 848 5768235090
Mocksville NC 27028 County File Number:
Date: .0 '7 / 1 8 / 2 0 1 6
Click below to Import an Image from an external location: Drawing Type: Construction Authorization
IMPROVEMENT PERMIT
Davie County Health Department
f 210 Hospital Street
_ P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID UNTIL: 7/18/2021
"NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit.
Applicant: Hope Homes of Davie County
Address: 321 Redland Road
City: Advance
State/Zip: NC 27006
Phone #: (336) 909-2910
Address/Road #:
Hickory Tree Rd
Mocksville NC 27028
Structure: SINGLE FAMILY
# of Bedrooms: 3
# of People:
"Water Supply: PUBLIC
Property Owner: Hope Homes of Davie County
Address: 321 Redland Road
City: Advance
State/Zip: NC 27006
Phone #: (336) 909-2910
Subdivision: Hickory Tree
S
n: Provisionally Suitable
SaproliteSystem? OYes QNo
Design Flow: 3 6 0
Soil Application Rate: 0 3
"System Classification/Description:
TYPE II A. CONY SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
'Proposed System: 25% REDUCTION
Phase: Lot: 15
Directions
Hwy 64 East, right on No Creek Rd. On left Hickory
Tree Rd
Minimum Trench Depth:
a
4
Inches
Maximum Trench Depth:
3
6
Inches
Septic Tank:
1 0
0
0 Gallons
1 -Piece: OYes Q No
Pump Required: OYes QNo OMay Be Required
Pump Tank: Gallons
1 -Piece: OYes ONo
Repair System Required: QYes ONO ONo, but has Available Space
Repair System
"Site Classification: Provisionally Suitable
Soil Application Rate: 0 3
u
"System Classification/Description:
TYPE II A. CONV SYSTEM (SINGLE-FAMILY OR 480 GPD OR
LESS)
( 'Proposed System: 25%REDUCTION
Minimum Trench Depth: a 4 Inches
Maximum Trench Depth: 3 6 Inches
Pump Required: OYes O No O Maybe Required
Page 1 of 3
CDP File Number 228407 -
*Site Modifications
County ID Number: 5768235000
❑ Open Fill Sheet
No grading or construction 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 requiremehts. ;
i
Site Plan The improvement permit shall be valid for 5 years from date of issue with a site plan (means a drawing not necessarily drawn to
scale that shows the existing and proposed property lines with dimensions, the location of the facility and appurtenances, the
site for the proposed Wastewater system, and the location of water supplies and surface waters).
Plat The Improvement Permit shall be valid without expiration with plat (means a property surveyed prepared by a registered land
O surveyor, drawn to a scale of one inch equals no more than 60 feet, that Includes: the specific location of the proposed facility
and appurtenances, the site for the proposed Wastewater system, and the location of water supplies and surface waters. Plat
also means, for subdivision lots approved by the local planning authority and recorded with the county register of deeds, a copy
of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale).
The Department and Local Health Department may impose conditions on the issuance and may revoke the permits for failure of
the system to satisfy the conditions, the rules, or this article: This permit is subject to revocation if the site plan, plat; or intended
use changes (NCGS 130A335(o). 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 (.19M(b)}
Applicant/Legal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps. Signature-, Date: I
'Issued By;
2140 - Nations, Robert
Authorized State Agent:
Date of Issue: 0 7/ 1 8/ 2 0 1 6
OValid without Expiration?
O C re ate CA?
01 -land Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. Box 848
Mocksville NC
Drawing Drawing Type: Improvement Permit
CDP File Number: 228407' 1
County File Number: 576$235000
27028 Date:
Q Inch
Scale: 06lock
QN/A = ft.
IMPROVEMENT PERMIT
Davie County Health Department
210 Hospital Street
P.O. sox 848
Mocksvilie NC 27028
CDP File Number: 228407 -1
County File Number: 5768235000
Date: 0 7/ 1 8 / 2 0 1 6
Click below to import an Image from an external location: Drawing Type: Improvement Permit
APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
hlocksville, NC 27028
(336)753-6780/ Fax(336)753-1680
Application For. Site Evaluation/Improvement Permit i7 Authorizztion To Construct(ATC) J Both
Type of Application: i 4cw System t:IRepair to Existing System ❑ExpansionlModification of Existing System or Facility
"'IMPORTANT"" THIS APPLICATION CANNOTBEPROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
Name to be Billed Ff lr'F Ilex—? ,^ s ontact Person 'Bac
Billing Address 3,� 1 Pr,A A V A4, A Home Phone v
City/State/ZIP Ara va—, o_-, rJ C :r -rnn 6 Business Phone .3 36, 509
Name on Permit/ATC if Di ercnt than
Mailing Address
FRIUM,KI Y INI'VKMAIION"llatetiouse/t,acultycomers tlaggea
NOTE: A survey plat or site plan must accompany this application. Included: U Site Plan "'Vlat(to scale)
(Permit is valid for 60 months with site plan, no expiration with complete plat.)
Owner's Name -r Phone Number
Owner's Address 3a t Ke t ra Y, rt a City/State/Zip A tWtk- r e
Property Address Lo 4 15 I,' ; !r r,r v i T? A City t 9 � ^ l,- � .t : f i r__
Lot Size Tax PLN#,
Subdivision Namc(if applicable) P -c le. rr--a 'Fr a Section/Lot#� �� 7,
1j " U
Directions To Site: & qa t } G f 4� ,n ! I �`;P E.'a . Lf'- T4- %rM u T,re_-'A
If the answer to any of the following questions is "yes", supporting documenudi �!p must be attached.
Are there any existing wastewater systems on the site? UYes 11No
Does the site contain jurisdictional wetlands? t Yes rNo
Are there any easements or right-of-ways on the site? ']Yes t3Ro
Is the site subject to approval by another public agency? taYes ENO
Will wastewater other than domestic sewage be generated? []Yes f3tVo
# People 4# Bedrooms 3 # Bathrooms Garden Tub/Whirlpool i::iYes KRo
Basement: C Yes Ao Basement Plumbing: I"Yes
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 :::IAccepted ..'.Ilnnovative (.,Alternative [:'Other
Water Supply Type: k County/City Water ri New Well I 'Existing Well H Community Well
Do you anticipate additions or expansions of the facility this system is intended to serve? C! Yes IN.
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. 1 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 corners and
locating a Flagging or staking the house/facility location, proposed well location and the location of arty other amenities.
Site Revisit Charge
Proms owner's or o Ker legal representative signature
Client Notification Date:
Date EHS:
Sign given U Yes ONO Account # 'v q
Revised 11/06 Invoice #
D