141 Timber Creek Road Lot 5P6rmittee;s --� , % DAVIE COUNTY HEALTH DEPARTMENT
Name: } 'll l ;-r`-r=�I •' Environmental Health Section PROPERTY INFORMATION
) P.O. Box 848 %
Directions to property:"' " �'� !- r� 6 N16cksville, NC 27028 Subdivision Name: [ r 171
Phone #: 336-751-8760
Section:_ Lot: )
1 f AUTHORIZATION FOR
WASTEWATER
SYSTEM
Name: Tax Office PIN:#� 7� _ U y
O -7)
SYSTEM CONSTRUCTION
0 1 / I / (t MT�Yi l/tC /4)(,�
AUTHORIZATION NO: 0 0 2 ': 5 -, t� //
G, / ) ., Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Permits. This FornVAuthorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article I 1 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE Z # BEDROOMS G( # BATHS 2. 5- # OCCUPANTS L"/ GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
I 2
LOT SIZE"" TYPE WATER SUPPLY V DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE L I )G AL. PUMP TANK GAL. TRENCH WIDTH, ROCK DEPTH 1\141
`1117" LINEAR FT. LY60 I
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PE�MJT LAYOUT -- �
r-
lug � I
- d��tt(
19 I. `
FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760.
OPERATION PERMIT
INSTALLED BY:
N1 -r
s� G
3` e
l
7
�o�
� I
AUTHORIZATION NO.� OPERATION PERMIT BY: DATE: `
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBEI ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN ASA
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 02/02 (Revised) 5567,
Pe `tt s `,u1, AIE COUNTY HEALTH DEPARTMENT
e:= 11Environmental Health Section
PROPERTY INFORMATION
P.O. Box 848
Directions to property, is Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
��.� r ii %Y /1 i l.: i l f i♦ t �(� WASTEWATER Tax Office PIN:#)'_71
7 01
SYSTEM CONSTRUCTION C;
AUTHORIZATION NO: 0 Q 2 .. 5 9 f, i ) L Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County 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 with Article I 1 of G.S. Chapter 130A. Wastewater Systems, Section.] 900 Sewage Treatment and Disposal Systems)
i
�, �• ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
+`, f , ; F, %* P" ' i ✓_ ; IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS /, # BATHS _2L # OCCUPANTS 41 GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE_�TYPE WATER SUPPLY �0' DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE 6 �(")G AL. KMP TANK GAL. TRENCH WIDTH / ROCK DEPTH _W LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PEI MJT LAYOUT
'. /� L � �� I 4 F• L.L.
J� y
s
\ fallylly U -r v
P
C GIN)�� e i ,
II FOR FINAL INSPECTION OF THIS SYSTEM PLEASE CALL BETWEEN 8:30 - 9:30 A.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (336) 751-8760. 1
OPERATION PERMIT -- --- — --- -- -- - - --�--^
SYSTEM_INSTALLED BY: "
iJ
Y � 11,4E
1
P'd
�; • ��` is fr �
W.
0
NO. 1C(` OPERATION PERMIT BY: . it { .1_i� % l/�. l DATE: I 1 I L
AUTHORIZATION
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBEJ ABOVE 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.
DCHD 07102 (Revised) _5� 6A-_ — I q��
`1
E
Appraisal Card
DAVIE COUNTM, NC
Page 1 of 1
12/5/2012 12:13:38 PM
BARNEY TENA L
Return/Appeal Notes: E7 -060 -BO -005
141 TIMBER CREEK RD
UNIQ ID 7051
706500
D199 -P34 ID NO: 5871047283
COUNTY TAX (100), FIRE TAX (100)
CARD NO. I of 1
Reval Year: 2009 Tax Year: 2013 LOT 5 TIMBER CREEK SECTION ONE
1.000 LT SRC= Inspection
Appraised by 19 on 11/04/2008 03007 BEAUCHAMP RD
TW -03 C- EX- AT- LAST ACTION 20100922
CONSTRUCTION DETAIL MARKET VALUE
DEPRECIATION CORRELATION OF VALUE
Foundation - 3
Standard 10.12000-
Eff. BASE
Continuous Footing 5.00 USE MOD Area UA RATE RCN EYB AYB
CREDENCE TO MARKET
Sub Floor System - 4
Plywood 8.0 Ol 01 2 307 101 69.69 163024199 199
%GOOD 1 88.0 DEPR. BUILDING VALUE -CARD
143,46
Exterior Walls - 10 TYPE: Single Family Residential
Single Family Residential DEPR. OB/XF VALUE - CARD
6,03
Aluminum/Vinyl Siding 29.00
MARKET LAND VALUE - CARD
50,00
STORIES: 3 - 2.0 Stories
TOTAL MARKET VALUE - CARD
199,49
Roofing Structure - 03
Gable 8.0
Roofing Cover - 03
Asphalt or Composition Shingle 3.00
TOTAL APPRAISED VALUE - CARD
199,490
TOTAL APPRAISED VALUE - PARCEL
199,49
Interior Wall Construction - 5
D wall/Sheetrock 20.0
Interior Floor Cover - 08
TOTAL PRESENT USE VALUE - PARCEL
Sheet Vinyl/Laminate 6.00
TOTAL VALUE DEFERRED - PARCEL
Interior Floor Cover - 14
TOTAL TAXABLE VALUE - PARCEL
199,49
Carpet 0.0
Heating Fuel - 04
PRIOR
Electric 1.00
BUILDING VALUE
151,06
Heating Type - 10
OBXF VALUE
Heat Pump 4.00
LAND VALUE
28,00
Air Conditioning Type - 03
PRESENT USE VALUE
0
DEFERRED#/ALUE
0
Central 4.00
TOTAL VALUE
179,060
oms/ athrooms/Half-Bathrooms
13.00oms
3FUS-0 0 +--------50--------+
P3/2/1
I FUS
I PERMIT
1,-0LL-0 1
I CODE DATE NOTE NUMBER AMOUNT
athrooms 5
1
I FUS -0 LL -0 +--20--+
+ - -20--+
2
- I 6 ROUT: WTRSHD:
TOTAL POINT VALUE 1101.00C I B A S I
1 I SALES DATA
BUILDING ADJUSTMENTS 1 7
6 1 FF. INDICATE
uali 3 AVG 1.000 4 +-9-+
I +7+-12-+ RECORD DATE DEED
SALES
++
Shape/Designl 4 1 FACTOR 4 1 1.050
+ - 11 - + BOOK PAGE M R TYPE /U /
PRICE
+ - - 20---+
Size 3 Size 0.950 1 F G D I I
00196 0539 8 199 FD U I
2200
TOTAL ADJUSTMENT FACTOR 1.00 I 1 1
0193 0914 4 199 WD U I V I0
TOTAL QUALITY INDEX 101 2 2 2
3 3 4
I I I
I I I
+--20---+11-+8-+-12-+
HEATED AREA 2,176
4FOP 8
+ - -19--+
NOTES
SUBAREA UNIT
ORIG % ANN DEP No OB/XF
DEPR.
TYPE GS AREA I % JRPL CS CODE DESCRIPTION LTH HUNITS PRICE
CONO BLDG# L/B AYB EYB RATE OV COND
VALUE
BAS1,034 10 72059 10 ON PAVING 7IS 1,35 4.0
10 _ L 199 1997 SS 40
2160
FGD 46 04 1442 1 STORAGE 1 1 19 15.0
10 _ L 199 199 S3 64
1843
035 264 55 GAZEBO 1 1 14 16.0
_ L 2005200 S3 88
2028
FOP 10
OTAL OB/XF VALUE
6,031
FUS 1142 09 71641
3 - 1 Story
FIREPLACE 2,250
Sin le
UBAREA
2 744 163,02
OTALS
BUILDING DIMENSIONS BAS=W2N3W9N7W2OS14FGD=W20S23 E20N23$S25FOP=S4E19N8W8S4W11$E11N4E8N1E12N24$PTR=NISFUS=NISESOS26W12S1W7S4W11N16W20$S15
$.
LAND INFORMATION
HIGHEST
OTHER ADJUSTMENTS
TOTAL
ND BEST
USE
LOCAL
FRON
DEPTH/
LND
COND
AND NOTES
ROAD
LAND UNIT LAND UNT
TOTAL
ADJUSTED LAND
LAND
USE
CODE
ZONING
TAGE
DEPT
SIZE
MOD
FACT
RF AC LC TO OT
TYPE
PRICE UNITS TYP
ADJST
UNIT PRICE VALUE
NOTES
FR RES
0100
0
0
1.0000
0
1.0000
50,000.0 1.000 IT
1 1.00
50,000.0 5000
1 1.00
OTAL MARKET LAND DATA 50,00
OTAL PRESENT USE DATA
9
9 1013
http://maps.co.davie.nc.us/ITSNet/AppraisalCard.aspx?parc6l=E7060B0005
12/5/2012
name: 1
Environmental Health Jection I . Lill .J.....
ll , ..,..
P.O. Box 848 jt j
Directions to property:`. f +' Mocksville, NC 27028 Subdivision Name: , ,r;. {., � "< � I
Phone #: 336-751-8760 sw
. i
y,;"j x 'fi% l"` �•'` Section:Lot:
AUTHORIZATION FOR r
WASTEWATER
SYSTEM CONSTRUCTION' Tax Office PIN:#•-
AUTHORIZATION NO: 2469 ' A Road Name: x� x rs�'' Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior
to issuance of any Building Pennits. This Form/Authorization Number should be presented to the Davie County Building Inspections
Office when applying for Building Permits.
(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
.—***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE f P # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No >
LOT SIZE TYPE WATER SUPPLY _ DESIGN WASTEWATER FLOW (GPD) % NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH Q..O ROCK DEPTH rrLINEAR FT.i` (
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
YI-f ?i rt /i
IMPROVEMENT PERMIT LAYOUT J �^�
4 /
7,,G
ie
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:,
.J�
neaan Jection
P.O. Box 848
Name: r�%'�/[ .✓ /%✓CJS/�®/�
Mocksville, NC 27028
Directions to pioperty: ` `— ' f; Phone #: 704-634-8760
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION
PROPERTY
YIIN�FORMATION f�
Subdivision Name:
Section:Lot:
® p`
Tax Office PIN:# '-' t'F
Road Name: Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County 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.
L(In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NOTICE THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED VALID FOR A PERIOD OF FIVE YEARS,
. i
RESIDENTIAL SI'�ECIFICEI`1'lilry:7tsvirrLu��-r•.-.--�•--_._..__.___.._.:��_.__�-i___,__..,._;.��__�x
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY 4 DESIGN WASTEWATER FLOW (GPD) NEW SITE L!' REPAIR SITE
/
SYSTEM SPECIFICATIONS: TANK SIZE )/;GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT.
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
7
-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 (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY.
.. �d 3 - �- S✓
Pem;;ttge's/- _ �, DAVIE COUNTY HEALTH DEPARTMENT
blame: Environmental Health Section PROPERTY INFORMATION
•� r ., P.O.
Box 848 T
g
Directio0's to property: .+` d . �' '. r Mocksville, NC 27028 Subdivision Name:
Phone #: 336-751-8760 ,
Section: Z Lot: "J
AUTHORIZATION FOR
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:# -a
AUTHORIZATION NO: A Road Name: Zip:
"NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County 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 with Article 1 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
.y***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
l ' `c? 1 r ��} 7 ;J���- ';' )•.��/ i if IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPE6IXLIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS r_2 # OCCUPANTS –7,!L— GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT /QT# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)! u !/ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH — ROCK DEPTH �f LINEAR FT. ' �
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
Al
"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: %
AUTHORIZATION NO. OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE 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.
DCHD 02/02 (Revised)
' AUTHQR ZATION NO: Q 9 3 0 DAVIE COUNTY HEALTH DEPARTMENT
Y ,�, Environmental Health Section PROPERTY INFORMATION
Permittea.'s l� / O • P.O. Box 848 irlf r'C'i'e6k
Name: f''[C�� /V Mocksville, NC 27028 Subdivision Name:
/--4, X-/ Phone #: 704-634-8760
Directions to property:
AUTHORIZATION FORSection: Lot:,
WASTEWATER Tax Office PIN:# � 6
SYSTEM CONSTRUCTION
'�R� ��
Road Name: � Zip;
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County 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 with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS � #BATHS 1 #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) 3K -e) NEW SITE_ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE //'r) UGAL. PUMP TANK � � —GAL. TRENCHWIDTH f Sn o
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
.6 e
"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 (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
o
L�"j
r
1
AUTHORIZATION NO. -9-4!�V OPERATION P 1 DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA THE SYSTEM DESCRIBED ABOVE 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.
DCHD 05/96 (Revised)
AUTHORIZATION NO; Q 9 3 Q DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's ( �✓� /�,D - / P.O. Box 848
Name: d� f� L /V Mocksville, NC 27028 Subdivision Name:
-634-8760 Phone #: 704
.Directions to property: Section: Lot:
AUTHORIZATION FOR. '5 �/ D rl /� �►
WASTEWATER Tax Office PIN:# _ f t
SYSTEM CONSTRUCTION /�
Road Name: CT��-t L� Zip.
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County 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 with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
DAVIE COUNTY HEALTH DEPARTMENT ,
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
v Permrttee' �4 4
t
Name 'Y+:�1 ✓��'g't'�f��
Directions to property: ? ^.1 :fir'. /`F •, r'
Subdivision Name:
Section: ;/ Lot:
IMPROVEMENT
PERMIT Tax Office PIN:# �+�� - ` - �--
ii a
Road Name: T �` s t �, i i4) Zip ��t"`� �j
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
construction/installation of a system or the issuance of a building permit.
(In compliance with Article 11 of GS. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
i� ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE R4TENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
r INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS ; # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD) NEW SITES REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH Z—,2 LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r c'c' lvti /fir /� 7 i c
47
"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 (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO. W -a OPERATION PERMITBY: DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICA E THAT ETHE SYSTEM DESCRIBED ABOVE 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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
i
}
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
` y Davie County Health Department
1
SQ%���fo� Environmental Health Section
P.O. Box 848
Mocksvillb NC 27028
(704) 634-8760
***IMPORTANT**** IMPORTANT THIS APPLICATION ;CANNOT BE PROCESSED UNLESS ALL
THE REQUIRED INFORMATION IS PROVIDED.
' 1. Name to be Billed Contact Person
' Mailing Address Home Phone
City/State/Zip Business Phone 7oL "7 ,57
2. 'Nam on Permit/ATC if:Different than Above
! " " Maili �dc.ress City/State/Zip
3. Applic nr For: [ ite Evaluation [ ] Improvement Permit & ATC
[ ] Both
{ 4. System to Serve: [y]'fiouse [ ] Mobile Home [ ] Business [-] Industry [ ] Other
is
5. If Residence: # People # Bedrooms # Bathrooms [ ] Dishwasher [ 1 Garbage Disposal
[ 1 Washing Machine (] Basement/Plumbing [ ] Basement/No Plumbing
6. If Business/Other: Specify type #•People #Sinks
' } # Showers # Urinals #: Water Coolers
If Foodservice #Seats Estimated Water Usage (gallons per day)
7. Type of water supply. (" Nounty/City. . [ ] Well [ ] Community'
8. 'Do you anticipate additions or expansions of the facility this system is intended to serve? [ ] Yes
If yes, what type?
w
t'
i'
EITHER A PLAT OR SITE PLAN
PROPERTY.INFORMATION REQUIRED: *** IMPORTANT *** OF THE PROPERTY MUST BE
y `SUBMITTED WITH VM APPLICATION.
Property Dimensions: :WRITE DIRECTIONS from Mocksville) TO PROPERTY
Tax Office PIN: # 5M 7 - S 3t �-� �/ _ �S TZ orA) C rc-c,.Lr3
Property Address: Road ame e�y,/ efI4 Z_U)e�k) JeWG 1-i—
city/zilp AoV qA--yG0-- 6
If in Subdivision provide information, as follows:
` Namt %/LI �� �02��.�' / ff/�.St= 22! ;
,
Sectior , ._ �_ Lot #:
s„
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued l.,;reafter are
subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application ,falsified or
changed: I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to th-: Authorized
Representative of the Davie County Health Department to enter upon above described property located in Davie Count% and owned
by Z.�j'ZJ Al L' l,•t !qxori3uct all ixtingprocgiures as necessary to determine the site suitabi ity.
DATE %� I % SIGNATURE ��►�i� /-�-----
Revised DCHD (06-96)
THIS AREA XtAY 13E USED FOR DRAWING YOUR SITE PLAN:
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION_/ LOTy5_
• Soil/Site Evaluation
APPLICANT'S NAMEDATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION ht h/e,— ( F_ee I e� ROAD NAME �t'�
Water Supply: On -Site Well Community Public �!
Evaluation By: Auger Boring Pit jam' Cut
FACTORS 1
2
3 4 5 6 7
Landscape position k
' /
L
Slope % 019
ell
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
4 i
Mineralogy�,
/•
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
S
LONG-TERM ACCEPTANCE RATE,
r/
SITE CLASSIFICATION: 4�
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01.90)
EVALUATION BY: '4 /
OTHER(S) PRESENT:
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
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
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