248 Dalton Rd (3)Phone: (336) - 753 - 6780
Davie County Health Department
Environmental Health Section 141W.
P.O. Box 848 ,
210 Hospital Street
Courier # : 09-40-06 ? 1
Mocksville, NC 27028
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacement Remodeling 4econnection
Fax: (336) - 7.53-1690
Name: IOFI" Jw. • Phone Number ' (Home)
Mailing Address: 8 Z W �iCfAr.o,uA1 th r 3 G' YJi % WWI (Work)
NL 2ZZi1 Email Address:oamtu.a.l.S eto� cas
Detailed Directions To Site: t es `1(Zi '%e� .— kj W Z'1IS 6t
Property Address: 2400 bqN�uti ,R 6c'V'S�✓uc
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: 'T as 4 lJ u\N.,,,.J Type Of Facility:
Date System Installed (Month/Date/Year):'%, 11- 144'1 Number Of Bedrooms: Number Of People:_
Is The Facility Currently Vacant? 0 No If Yes, For How Long? N(9 (9 T C y f z
Any Known Problems? Yes ® If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility:Mj�,�k u. —Number Of Bedrooms: (A Number of People r:
Pool
Requ
Requested: 5 •Z.S 1'l
For Environmental Health Office Use Only
prove �Disapproved I— �U— y� /�
Comments: / / (.(i� A T U I Y1 �y ' S v1 1 a do '' D a ( (�i/Y'�'- —&u 01-"
Environmental Health Specialist z'(A"." If Date: 5 jA5j;2p) j
*The signing of this form by the Environmental HedW 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 Check Money Order #
Amount:$ Date:
Paid By: Received By:_
Account #: Invoice #:
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Davie County, NC Tax Parcel Report Wednesday, May 3, 2017
WA1dNIAU: i'Mb 1S NUT A b1UKV 'Y
Parcel �nfortiattctti
Parcel Number:
J600000033
Township:
Mocksville
NCPIN Number:
5757190454
Municipality:
Account Number:
8306865
Census Tract:
37059-805
Listed Owner 1:
BANK OF THE OZARKS
Voting Precinct:
SOUTH MOCKSVILLE
Mailing Address 1:
PO BOX 168
Planning Jurisdiction:
Davie County
City:
SHELBY
Zoning Class:
DAVIE COUNTY R -A
State:
NC
Zoning Overlay:
Zip Code:
28151-0168
Voluntary Ag. District:
No
Legal Description:
TRACT 1 DALTON S/D
Fire Response District:
FORK,MOCKSVILLE
Assessed Acreage:
3.40
Elementary School Zone:
CORNATZER
Deed Date:
10/2016
Middle School Zone:
WILLIAM ELLIS
Deed Book / Page:
010311192
Soil Types:
WeB,RnD
Plat Book:
0009
Flood Zone:
Plat Page:
032
Watershed Overlay:
DAVIE COUNTY
Building Value:
0.00
Outbuilding & Extra
0.00
Freatures Value:
Land Value:
27080.00
Total Market Value:
27080.00
Total Assessed Value:
27080.00
OPV IF All data is provided as is %a thout wamnty or guarantee of any Wnd either eapressed or implied including but not limited to the
Davie County, implied wanantles of merchantablity or fitness for a particular use. All users of Davie Counl s GIs mbsite shall hold harmless the
County of Davie North Carolina hangouts, consultants, contractors or employees fmm any and all claims or causes of action due to
SOU 4; NC or arising out of the uses, inability to usethe GIS data provided by thiswebslle.
` `f1 D_ AVIS COUNTY HEALTH DEPARTMENT s N
.IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION �Q_/ gyp
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t: ��.;,,. ,.•.:.�..,; •y, y. ,P' � PLANS ORTEIKENTENDED USE CRANGE. YOUR WASTEWATER
ENVIRONMENPAL FB3AL171 SPECBU]SI• DATEISSUrD �GTH65YSTEM. SEE TIES PERMIT BEFORE
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To
RESIDENTIAL SPECIFICATION. BUILDING TYPQt)�%.#BEDROOMS , 4 #BATHS R OCCOPANIS 4_OARBAOEDLSPOSAi.�(�ulorNo
COMMBRCLIL SPECIFIGTION:.FACILITY TYPE_ MPBOPLE_ SPEDPLE)SHB*1'__ 8S8ATS_' IINDUSIRLILWASMYceor No
LGTSM�+� TYPEWATMSUPPLY� DESIGNWASTRWAT70t FLOW (GPD) LAT"NEW SDb� REPAIESDE
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SYSTEM SPECB:ICATIONS: TANK OO GAL.,PUMPTANK GAI.. TRENCHWIVI71 ROCK Dpi_—LINEARFT.�'
R EQUI RED SITE MODIFICAT'IONS20NNTIONS:
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+'CQNTACt•ARHPRESFMA77YH OF THHDAVIB COUNTYBEALTHDEPARTMENI FORFINALINSPECIION OFTIW SYSIPM
HEIWFEN 530-9:30AM. OR 1:00.1:30.PAL ONT'BE DAY OF INSTALLATION. TELEPHONE# IS (704) 634-8760.
OPERATION PERMIT
SYSTEM INSTALLED BY:y�`^
AUD(ORFLATIONNO.`�/� OPERATIONPERMUBY: ///—' DATR'
- TG HISSUANCE OFTEN OPERATION FERMITSHALLINDICATE THATTHE SYST04 DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE II OFOS. CHAF ISE 130A, SBCM)N.190D"SEWAGETTIEATmENTANUDISPOSAL SYSTEMS", BUPSHALL INNO WAY BETAKEN ASA
OUARAMEETBATTHESYSIEM WILLFUNCIION SATISFACTORILY FOR ANY OIVENPERIOD OFTLNE.
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