176 S Angell Rd � ` � '' ' DAVIE COUNTY ENVIRONMENTAL HEALTH �
` P.O.Box 848/210 Hospital Street �
Mocksville,NC 27028 �
_ , (336)753-6780/Fax#(336)753-1680 .
� REPAIR OPERATION PERMIT
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Accc►u�t #: 990005956 Tax Plf�:EH#: G50000011 �:.
Bi!!cd To: James Peebles SuE�divisiart Infa: �
Refer�E�ce Name: REPAIR PERMIT . • �LucationiAddr�ss:`� 976 S.Angell Road-27028 : t'_ ,
Pro�c�sed Fa�ifify: Residential Repair Pca�erty�ize:-- :87 Acre -
E�TC N�amber: 5985
**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 systern will function satisfactorily for any given period of
time. � �
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System Type:�_S.T.Manufacturer.S��r*- Tank Date — Z Z Tank Size /l GQ , _
Pump Tank Size ..i Bedrooms�
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System Installed By:�7/^f(,�Iti- ��i�{' (�'L(!ti` Installer#: Date: Q��
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GPS Coordinate: , .
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Environmental Health Specialist: Date: � 16�
DCHD I 1/06(Revised) �
� ' DAVIE COUNTY ENVIRONMENTAL HEALTH
P.O.Box 848/210 Hospital Street
Mocksville,NC 27028
. (336)753-6780/Fax#(336)753-1680 ,
AUTHORIZATION FOR WASTEWATER SYSTEM C01�1STRLJCTION •
� Acc�u�t #: 990005956 . � . '� '�ax Pf�€iEH#: G50000011 . .
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- 8illcs�To: James Peebles � _ ' ' Sufa�irri�iaii In��i: . ;
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R�fer�E�c� f��a��e: REPAIR PERMIT . . , ::;.Locatio#��Ai��r�ss:�:176 S.Angell Road=27028: . -.. ., . :^'
s:
F'rnpc3s�;e] Fa�:ility: Residential Repair :;,.. ; • . , ::� ; Pfo��r#.y�iz�:;,-:;,.87 Acre - '
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� rx SiteType: .�?�Iew ❑Repair ❑Expansion
�TC �t�amber: 5985 , .. _ _
r, **NOTE**This Authorization to Construct(ATC)MIISTBE 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 AUTHORIZATIONTO
� CONSTRUCT IS VALID FOR A PERIOD OF FNE YEARS. This ATC is subject to revocation if site plans,plat
F .' or the intended use change. '
:
Residential Specifications: #Bedrooms 3 #Bathrooms ? #People��Basement0 Basement plumbingG
Non-Residential Specifications: Faeility Type # People #Seats �
Square Footage(or Dimensions ofFacility) ' .
� '/ Lot Size •�S�(.r'C. Type of Water Supply: �County/City �Well �Community Well �
' System Specifications: Design Wastewater Flow(GPD),��Tank Size�O�GAL. Pump Tank GAL.
r, ;. . Trench Width�Z Max.�Trench Depth� Rock Depth� Linear Ft.�
Site Modifications/Conditions/Other: � � ���I;���h
Contact the Davie County Environmental Hefilth Section for fina 'nspection of this system between '
' 8:30—9:30a.m.on the da of installation. Tele hone# 336 751-8760.
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Environmental Health pecia ist • Date:
DCHD 1]/06(Revised)
• • • � � DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST
APPLICATION IP/ATC OSWW REPAIR
Name _ ,� Telephone Number �uG'-Z��
Address; �. � � l •
Mailing Address (if different from above) � ��
Email Address: __ , 7 �,.
Subdivision Name Lot#
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Directions j,� <�l�/ /�qyiU �� r� _ �1 �p �, ,��`� , dN
��-F.��.�-'�N 2��,-�.
Date System Installed � Name System Installed Under /��/�
Type Facility �u� Number Bedrooms� Number Peop el Served
T�`�'//�}yy���ppyy Water Supply Specific Problem Occurring '��� ���5'
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Date Requested I L'•2-/2 Info Taken By
THIS IS TO CERTIFY THAT THE INFORMATION PROVIDED IS CORRECT O THE BEST OF MY
KNOWLEDGE,AND THAT I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION.
Signature of owner or Authorized Agent
Initial Fee Date REHS
Revisit Charge Date Reason L�l� g�0��
Revised 2-2011
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-. ; R, �- ; DAVIE COUNTY ENVIRONMENTAL HEALTH SERVICE REQUEST •. �
` � �1PPbICATION IP/ATC OSWW REPAIR � _, �
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Name.� l Q �.S � Tele hone Number ; 2�0-Z�$� ,
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Address �.5; � � � /� d �S�/i ��'
Mailing Address (if different from above) �' � U�(�U�� ""
Email Address: � 7 �
Subdivision Name ' � ` Lot#
Directions j�� "'T��v /VI�IiN l�`r,�rr���1 T/� P CJD � .�, NT/j � 6N
-_��1� I���/�_QN /.�iq�i� ' �`f z . .
.�_�• Date System Installed � ` � �` " Name System Installed Under /�/7
.. . Type Facility �u$� - r Number Bedrooms � Number People Served �
_ Typ Water Supply � � Specific Problem Occurring.�i� �fii/0 C +
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Date Reques,ted /b-2-/Z � %" Info Taken By; �
THIS IS TO CERTIFY THAT THE INFORMATION�PROVIDED IS CORRECT O THE BEST OF MY .
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KNOWLEDGE,AND THAT I UNDERSTAND THAT.I AM RESPQNSIBLE FOR ALL CHARGES INCURRED
FROM THIS APPLICATION. t �` : ,w � '�� �� ' � .
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Signature of owner or Authorized Agent ,_ f
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Initial Fee Date� _�� °�REHS , ;I
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� Revisit Charge + Date� ;'; �Reason =��:f t'�>��O�l�- '
Revised 2-2011 _ _ : `4 ;, 1� _
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�/ I WARRAFfI'Y DEED-Porm WD�601 . y � �A Prinmd�nd for..le b�)un�tllhm�!r Co..Ine..Y�dkiri.�lb,�N,�G
� STATE OF NORTH CAROLiNA, navie County. � '
' THIS DEED,Mad.�hb 1i da�of Januarv � .19�.p��„dy��„ 'rt�oDORE SRowN and
� wife, JANIE LOIS SROSQN o{ Davie �unry
and�ateo(N«�hC.roWw,hercinaherea�edCnntor,�nd 1�NLTH M. WILLARD and wift. KAREPI 8. WILLAItD .
' . o� DdVie ' Countq�nd Spee of Nonh Cud1n�,hercinafar � � .
� nUed G�antae.w�ho�a perm�nent mailint�ddrea b � . .. .
.. *}ff��Rt�tfl#AMRiit�kT�,]!*Afrflf��fAff�ffffAR��• ' � � . �
WITNESSETH:'fhai th�Cnneor,fo�and in eon�denHon of the�um o[ � �o11an �
; �nd other 6oad and vdwble mnsidmtio�q to him In Fund R�id b}�tl�e Granta,tAe tetdpt whereo[b hettby aeknowte�cd,lw`i.en,�nnced,bupfned,w1d
� �ed convcyed,aed by them preunu don�ive,Qant,bapm,uU,comry�nd confvm unto the Cnntee,6L heln�n�a mcceuon�nd u�ig�u,premiui in � �
Moeksville Township, D8Vie Countr,No�th Carolina,de�cn'bed u followi:
( ''a'
BEGINNING at a point in the center of Angell Road (S.R. 1466)J runs
� � thence South 86° EasC with Hugh McCla*irock's litle 408 feet to e►n iron
pin, W. K. Whitaker cornert C�ence So•:th 4• West 532.62 teet to a stone,
r ; Donrae Cook's comers thence South 41• West 840.24 feet to a atone, Paul
� Willard's cornert thence North 58• West with Willard's line 313 feet to
an iron atake, corner of Kenneth M. Willardt thence vith the willard line .
- North 46• 31' East 18Y.94 feet to tsn iron stake� thenee North 55• West
„ 240 feet to the center of Anqell Road (S.R. 1466)� thenes with the center
. o! said Angell Rond to the Seginninq, containing.16.4 acrea. more or lese, .
� an8 beinq all of the landa on the east side o! Anqell Road as conveyed to
t the qrantors by deed recorded ist Hook 54, page 398. Davie County Registry. •
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$20.00 ' ;� . $4.00 54.00 ' :.
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. T6t�bo.e 6nd Mu conrryed to Gnn[or br .So�book No. ,Ta�e .
TO HAYE AND 7'O HOLD 7fie�bo.e dncribed prcmlut,whh aD th��ppurteiuncn�he�euew Eelon�iny or in�wb�e appectaWn�,anto tM Cnntee.h�
hefn andlor wceeaon�nd wi�n�forerer.
A�ehe Gnntot eovenaaa th�t ht h�eised of qid premitn in f«.�nd Iw dw�h�w con.e�th�amt In fee dmple:�h�t uN premhn w fm Gom ei.
enm6rancq(wi[h the e:cepNoru�bova�tated.ff anr):and that be will w�r t�n t�nd de[rnd the ald tftb to the rms apinrt ehe lawful t46nt of dt perwm ' .
. .� wd�omwtwer. . . . . . . � . .
Cvhen rc te.c�u b�n.de m[he Grantor or Cnnue,tM dn�I.r�h.tl b�d�de the lunt�nd tha muculfn�ihdl Inelodt tLe Gminlne er the nenter.
i IN WI7NE WHE EOF.7Le nmw Iw Rereuew�et 641und u�d�ed.the�.y a�a r��r�u,e,.e...tokM � � . � �
lsts X �� �f!—�. r�'L,(f�
� .._._! (SEAL) yT , _ (SEAL)
(SEAL) ,IM1�. :+:"._.. .�(SEAL)
� STATE OF�N�R7�H,C�A�tSOLIJ ' DHVie �p7jy, � ,.�'�.;: �`' •, . .
�� .!�[Y'.�c=�!(� 11'�..
a Notur Public of uid Counry.do herebr eenifj�that%C r
j Theodore 8 rn.and wife, Janie Lois Hrown _ �: •� .�� __
' Cnntor,perwnallr+Ppestcd bcforo me thb dar ind acknowled`ed the exeeution of tAr fore6oin�deed. ' �" ;,^v ..•:.�
� W imeu m�hand�nd nonrial ud,thb the �� dq ot < ,• 19�1
� . _.x4./YY 4 <�,<. �.. :• �
My Commistion E:p'ves:n�(Q�C�h ./ `"'--�..�1'(.F.�SSAL�
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57ATE OF NOR71i CAROLINA CWNTY. .
1. ,�Notuy Publie of uid Countr.do henb�eerel[r eha�
. Crmtor,perwnally�ppnred be[on m�thb dar�nd uknowled�ed the exeeudoa of t!w forc`oin`dee4 . �
W itnen mr hand�nd noueiii�ed,thi�the. dar ot ,19�.
MyCommWbnE:pire» ,N.P.�SEAL] '
SfATB OF NORiH CAAOLINA, DAV�.e m�Nry, . , . �
Tfie fotejoing terdAateQQ of nrm R_ Slui rn�� NO�,$��O Ot pc1�f19011 QO'1�1t}► .
b(�tettified to be rnrcect.Th6 irotrument ra prc�ented fot rcgtswtlon th4 6 a�y or ��h ,19.�..
at 11•3$ A.M.,EOm.,and dulr rceorded in the offut ot the Re�sster ot Deed�o! DAVie ��ti,
NortA Cudina.in Dook��.P+ie��. . .
Tfi4[he 6 dar of ��1 .A.D.,19 s�. � �
J. K. smith er�o./0�..�
Realuer o!Deed+ �(.Deput�Re�irtm otDeed� ' �
ihbDeeddrawnbr William E. tiall, Attorney at Law
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