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205 Becktown RdDavie Countv, NC � TaY ParnPl R er�nrt Wednesday, October 12, 2016 Parcel Number: NCPIN Number: Account Number: Listed Owner 1: Mailing Address 1: City: MOCKSVILLE State: WARNING: T1i1S 1S NOT A SURVEY Parcel Information M600000020 Township: Jerusalem 5755157221 Municipality: 82532919 Census Tract: 37059-807 MILLS JOY GORE Voting Precinct: JERUSALEM 205 BECKTOWN ROAD Planning Jurisdiction: Davie Counry Zoning Class: DAVIE COUNTY R-A NC Zoning Overlay: Zip Code: 2702&0000 Voluntary Ag. District: Legal Description: 0.988 AC BECKTOWN RD CALC Fire Response District: Assessed Acreage: Deed Date: Deed Book / Page: Plat Book: Plat Page: Building Value: Land Value: Total Assessed Value: °��'�' Davie County, `'��„�� NC 0.98 Elementary School Zone: 9/2011 Middle School Zone: 008690793 Soil Types: 0004 Flood Zone: 048 Watershed Overlay: 0.00 Outbuilding 8� Extra Freatures Value: 19340.00 Total Market Value: 23840.00 No JERUSALEM COOLEEMEE SOUTH DAVIE PcB2 DAVIE COUNTY 4500.00 23840.00 . . �, , . . .: - .'. ;. . .. , . . _ . _ . ���� AUTxoluzaTior� rro:' O 8 5 S DAVIE COUNTY HEALTH DEPARTMENT - � � rr �- ' Environmental Health Section PROPERTY INFORMATION r Per�ittee's � j °�—�� P.O. Box 848 Name: �,�„'�1'� ?��` .,�.), ���°�'ra,./ Mocksville, NC 27028 Subdivision Name: � J Phone #: 704-634-8760 Directions to property: �i'c"✓' 1x'�•r ��_ �"' r.i Section: Lot: AUTHORIZATION FOR WAST'EWATER Tax Office PIN:# •��..�`� � � - ! �tc� SYSTEM CONSTRUCTION 'I�T`�`"}Z��' , � � '.. Road Name: ,--�y�t a lp: �%7'.� X **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLJED by the Davie County Environmental Health Section prior to issuance of any Building Pernuts. This Forn�/Authorization Number should be presented to the Davie County Building Inspections Office when applying for Building Pernuts. " (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ! rt� % � j,-' , �, ***NOTICE*** THLS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �"`��•'r'_�� : r� �' ,•:; �: �".�`� �`; .�;� i, ,�- "i �> ;: IS VALID FOR A PERIOD OF FIVE YEARS. ENVIRONMENTAL HEAL H SPECIALIST DATE ISSUED 4x,.:�.-..., r� . _ , . _. ,: : � - . . . . . �� . . , . . , � � . .: � . _; , � ,; ^ ,_. ; ,: _ . - : . ' �,:;' - -- � t/i > a . _ _ ?` Q �` �"'����� :._ „� r ,; ;,„ ' 't DAVIE COUNTY HEALTH DEPARTMENT ��� `- � � � �--- ���`'�--�' .� ' •„' �' 4 IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION _ . F,> - �.�;,:.�, , � _ Perr.�ittee's ,: j � , � Name• �' .� 9 ��_,:,�,t�=r��':':�„� � Directions to property: �' i ,� �� Subdivision Name: Section: Lot: IMPROVEIVIENT - PERMIT T� Office PIN:# �` ..`.+�.�� ,� �'T _ r�, n;'.;f' ,,. � Road Name: ,�`�'.�= � � �:`.%-' �'� � t ��ip: � - =-'�'� **NOTE** This Improvement Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system. An ALJTHOitIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the construction/installation of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) � , ***NOTICE*** THIS PERMTl' LS SUBJECT TO REVOCATION IF SITE � j t�� •�'- �� � -' t���' �::;; �' PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TI�IIS PERNIIT BEFORE INSTALLING TI� SYSTEM. RESIDENTIAL SPECIFTCATION: BUII..DING T'YPE(� # BEDROOMS •,.� # BATHS '�)_ # OCCUPANTS T`% GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS ___ INDUSTRIAL WASTE: Yes or No LOT SIZE .�.�Ir?- TYPE WATER SUPPLY �_ DESIGN WASTEWATER FLOW (GPD) �_l�> C� NEW SITE� REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZEi„�„�"_GAL. PUMP TANK GAL. 1RENCH WIDTH •_7�' ROCK DEPTH � LINEAR FT.�s''�/.7� OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT .�-�--�~--�-�-~-�S'o';r3x'7�-' -�,�� yDX3Xl� � **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: _� > � �0 3 � Qo X�x�2 1d x.���a .� D�� ° AUTHORIZATION N0. �OPERATION PERMIT BY: �� Dp�; �%F< "Q' **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 WII,L FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OS/96 (Revised) 0 � � APPLICATION FOR SITE EVALUATION/IMPROVEMENT . Davie County Health Department Environmental Health Section P. O. Box 848 Mocksville, NC 27028 (704)634-8760 ;(� �� �1 �� , MAY - $ 1997 ...,�-r,, '.E'.1f4 �::�a.�.6. ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed � C/�IC) -S �C �TS QK� Contact Person D� �4x� ��� �5 °� Mailing Address % � 3 QEC! �OW � � 04 � Home Phone�id `�J � 8 `�- �� � % ��3553 City/State/Zip /�oG �S v� il� ,�% % �%�v� g Business Phone(9��5 6 iO �f'�'�/`//O 2. Name on PermidATC if Different than Above Mailing Address 3. Application For: 4. System to Serve: 5. If Residence: ❑ Site Evaluation ❑ House �` Mobile Home # People o� City/State/Zip ❑ Improvement Permit & ATC 0 Business ❑ Industry # Bedrooms ,�_ �� : • 1 ❑ Other # Bathrooms � �' Dishwasher ❑ Gazbage Disposal � Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing 6. If Business/Other: # Commodes If Foodservice: Specify type _ # Showers # Seats # People # Sinks # Urinals Estimated Water Usage (gallons per day) # Water Coolers 7. Type of water supply: � County/City ❑ Well ❑ Community 8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes � No If yes, what type? PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE SUBMITTED WITH THIS APPLICATION. Property Dimensions: � � L'j�� I Tax O�ce PIN: # 5753 _ i s _ �aa 1 I � � Property Address: Road Name /�63 Qee lt '}'own� �.� I I City/Zip /noc �-5�� 1�� , ,r�� a �oa � ' , I � If in Subdivision provide information, as follows: Name: Section: Lot #: WRITE DIRECTIONS (from Mocksville) TO PROPERTY: �,�>l� .���y � a i sauT�t � A�. /r-s ,�Gs T' �,vTr'�csc�CT.� aE' SS�1 �-6al �, T�RcrsC /�n'1 �G�r�sr C Tc.rr� �e �t o�J Bec�Tou.�v D�Z.v� c�c j� � . SEG'c7.c���/1'/G./ box o�J This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter aze subject to suspension or revocation, if the site plans or intended use change, or if the information submitted in this application is falsified or changed. I, also, understand that I am responsible for all charges incurred from this application. I, hereby, give consent to the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by � El�f /v �t�e � S o� to conduct all testing procedures as necessary to determine the site suitability. 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'� .• � � �, ,'st� � q . � � f, �.� .: x, ' ... � . .� _ x. .+�. � � '�'�' ^� '� � �� � � '� �r _ E L � N -- 6 / � � �� � �a � �� �� � � � ��� � - � � _ � � .�:= � � �" �� � � � �` � ��� N �� . - :' � ::, � _ .�� ,. ,.� � � ._ - � -:' +�� � ° � �n s*� -'��a � � � : �� � � �'«- c'���+ � �� ' a � , � , . � . , � �, : �ri _ : ,: „ ;,�„ s _,. -. -� � � a ,,�._., , ���-,. - _ <a E�.���, n���� � f�� pj _. . „ .. . ..�. ,�� _ . , e � � . , � • � � ' , • ' DAVIE COUNTY HEALTH DEPARTMENT ,.-' Environmental Health Section SECTION LOT SoiUSite Evaluation APPLICANT'S NAME �.I%���SD/v DATE EVALUATED ���'�� PROPOSED FACILITY ��� PROPERTY SIZE c��%C SUBDIVISION ROAD NAME �� L' �DltJ�1 � Water Supply: Evaluation By: On-Site Well Community Auger Boring � Pit Public t/ Cut SITE CLASSIFICATION: � LONG-TERM ACCEPTANCE RATE: � REMARKS: DCHD (01-90) EVALUATION BY: OTHER(S) PRESENT: LEGEND Landscape Position R- Ridge S- Shoulder L- Lineaz 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 Wet NS - Non sticky NP - Non plastic FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm SS - Slightly sticky S- Sticky VS - Very Sticky 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 MineraloEv 1:1, 2:1, Mixed Notes Horizon depth - In inches Depth of fll - 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 - gaUday/ft2 ■����■ ■����■ ■�■■�■ ■�■■�■ ■����■ ■�■��■ ■���■■ ■�■■�■ ■����■ ■����■ ■�■■�■ ■■■�■■ ■■��■■ ■■��■■ ■■■■�■ ■��■�■ ■■�■�■ ■■�■■■ ■�■■�■ ■■■■■■ ■����■ ■■■��■ ■�■�■■ ■�■■�■ ■�■ ■ ■����■���■ ■■■��■��� ■■���■�■ ■■���■���■ ■■■■■■■��■ ■■■■■■�■■■ ■■■�■■�■�■ ■■���■■■■■ ■■■■■�■�■■ ■■■■■�■■� ■���■��■ ■��■■����■ ■��■��■■■■ ■�����■■�■ ■��■■■■■■■ ■�■■�����■ ■��■■■■�■■ ■��■��■�E� ■�■ ■��������■��■�■■��■�����■ ■��■�■��■■�■■�■��■■��■�■■ ■■■■■■■■■■�■■�����������■ ■■■�■�������■■���■■��■�■■ ■■■�■■■■■��■�■���■■■�■�■■ ■�■����■�����■■■�■��■��■■ ■■�����■��■��■��■���■�■■■ ■�����■■�■■����■■■�■■�■�■ ■���■�■��■■■■�■■■■■■■■��■ ■■��■�������■�■■■■■■�■■■■ ■■�■■■■�■■�■■���i�������■ ■■�■����\�■■■�■■■■■■■■■�■ ■�■■■■■■■■■■■��������■�■■ ■���������■■■■■■�■■■■■��■ ■�■�■■■■■■■■��������■��■■ ■�■�■ ■■■�■ ■■��■ ■■��■ ■■�■■ ■■��■ ■���■ ■���■ ■��■■ ■���■ ■■■�■ ■■�������■■�■ ■�����■■■■��■ ■■�■�■■��■��■ ■■��■�■��■��■ ■■■■■■���■�■■ ■�����■■■■��■ ■��■■■����■■■ ■�■���■■■■■■■ ■�■■����■�■■■ ■�■����■■���■ ■�■■■■■���■■■ ■■■�■�■�■■ ■����■■�■■ ■■■■■����■ ■���■■■■■■ ■��■■■■■■■ ■������■■■ ■■■■■��■�■ ■��■■■■■�■ ■�����■�■■ ■■■■■■■��■ ■��■■■■��■ ■�■■■����■ ■������■■■ ■��■■■���■