327 Cedar Grove Church Rd Davie County,NC Tax Parcel Report Monday, September 26, 2016
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327 �
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WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number: K700000074 Township: Fulton
NCPIN Number: 5777058467 Municipality:
Account Number: 10912000 Census Tract: 37059-804
Listed Owner 1: BROWN KELLY G Voting Precinct: FULTON
Mailing Address 1: 327 CEDAR GROVE CHURCH ROAD Planning Jurisdiction: Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27028-7114 Voluntary Ag.District: No
Legal Description: LOT 3 JESSE J BROWN EST Fire Response District: FORK
Assessed Acreage: 0.69 Elementary School Zone: CORNATZER
Deed Date: 6/2004 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 005570233 Soil Types: PaD,PcB2,PcC2
Plat Book: 0008 Flood Zone:
Plat Page: 080 Watershed Overlay: DAVIE COUNTY
Building Value: 196650.00 Outbuilding&Extra 0.00
Freatures Value:
Land Value: 9880.00 Total Market Value: 206530.00
Total Assessed Value: 206530.00
�v All data Is provided as Is without warranty or guarantee of any kind 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 website shall hold harmless the
County of Davie,North Carolina,Its agents,Consultants,contractors or employees from any and all claims or causes of action due to
r'pU N{i NC or arising out of the use or Inability to use the GIS data provided by this website.
Permittee s�e`/ ,�����
DAVIE COUNTY HEALTH DEPAME T
Name. ,/ /� Environmental Health Section d� PROPERTY INFORMATION
i cit
f P.O. Box 848 t
Directions to pcopert}S`� Mocksville,NC 27028 Vi
ivision Name:
.I' '` ,�-� r ; l,' Phone#:336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION �—- -
AUTHORIZATION NO: 002614 A Road Name:_Of % P Zip -7D U
**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.1900 Sewage Treatment and Disposal Systems)
• a/ %` 1 %, "`` t/ ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ir "
F'
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS_lv^#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 SIZ5&rl G GAL. PUMP TANK GAL. TRENCH WIDTH'^ ROCK DEPTHX> / LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
cz �'
� r
--❑ 1_
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
SYSTEM INSTALLED BY: O Ill
b C
NN
AUTHORIZATION N OPERATION PERMIT BY: DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 0202(Revised)
r
_, Pe "'tiee , DAVIE COUNTY HEALTH DEPARTME T
Environmental Health Section h (� PROPERTY INFORMATION
P.O. Box 848 �P b
Directions-to property. Mocksville,NC 27028 ivision Name:
,f Phone#: 336-751-8760 -
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: 002614 A RoadZN �2dG1� /�P Zip:x270 22j
**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.
is
V ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
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 SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZF, L G GAL. PUMP TANK GAL. TRENCH WIDTH�—�" ROCK DEPTH!-� LINEAR FT. .
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
iz
%.
{
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
SYSTEM INSTALLED BY: �!/Ol/�J � GY 1 ✓,l�I
r ( RS
/
Tle
M
AUTHORIZATION NO, OPERATION PERMIT BY: DATE:
�j
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREATMENT AND DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE TAKEN AS A C
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
,� DCHD 02102(Revised) f'.
I'd E` ; IE COUNTY HEALTH DEPARTMENT
TEnvironmental Health Section
` FEB - 2 2006 I PO Box 848/210 Hospital Street m%✓ �� /�/ `
Mocksville,NC 27028 T
t , Phone: (336)751-8760 Shmd'Zo- M qf-k W by
ENVIRONMENTAL HEALTH sb/'M�
'ELM-1TEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING,( RECONNECTION ❑
Name: 4 \ 673 . 118/ZD W tj Phone Number: X33G. 798-- 5/92-_(Home)
Mailing Address: ,3� A2 G R.Dv E Cl . )ZID (Work)
Sv -7-7024-
Detailed
02
-7-4
,
Detailed Directions To Site: to 6 EJ4� % & A2 6 JG ell. � / 2J �� � 4 P � /���
,Jaa LAI BG o Le-f r A�� s,b�. l �2 S l02�� �A/�•� l�ouS�
Property Address:^3 02� l'��je2 O?ooz I'd.
Please Fill In The Following Information About The Exis 'ng Dwelli . 4 ea1bgk1 kNouJ Why 'N-�W
r- �1e DVip
� O1 �SySfeyy' Mo
Name System Installed Under: �W')1Wi6 Of Dwelling: M
Date System Installed(Month/Day/Year):19W 100 V(D Number Of Bedrooms: '� Number Of People:
Is The Dwelling Currently Vacant? YesX No❑ If Yes,For How Long? StNcfi 19-:9
—
Any Known Problems?Yes❑ Nod( If Yes,Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling: Number Of Bedrooms: Number Of People:
Requested By: �6& Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments:
Environmental Health Specialist Date
'"The signing of this form by the Environmental Health 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:
Paid By: Received By:
Account #: Invoice #:
�.,35.�;..'u�1.fs,. ,:F O ._. - _ - .•-s' � s� - _ �.i..�y� ..f... -. _.- a. �t yw .- -.,f--.."�
DAVIE COUNTY HEALTH DEPIARiENT
Environmental Health Section �- , (.till'(LU�1�r
PO Box 848/210 Hospital Street m% ,
!� Mocksville,NC 27028 (/
Phone: (336)751-8760 n s . �ha,��C' M vkp y
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT❑ REMODELING,( RECONNECTION ❑
. ll �
Name: 1)\ �W N T Phone Number: 33(..q98'- 5192— (Home)
Mailing Address: 3,: A2 G mDu E (Work)
NC
Detailed Directions To Site: w
EAS C'PtiAQ Gioo. e/J. t2D %2j R; ' AP,P �Z /I1%e
o Lem L
Property Address: lPDA2 arzooz
Please Fill In The Following Information About The Exis 'ng Dwellin . �ye 9"
Please rub lCNauJ w��0 �N
Name System Installed Under: I /� Ove�C �i o v s!' w�h T Of Dwelling: ��✓�'J�
Date System Installed(Month/Day/Year):OVE/Z &O VID Number Of Bedrooms: 'C Number Of People:_
Is The Dwelling Currently Vacant? Yes X No❑ If Yes,For How Long? Si tic F_ QaZ
Any Known Problems?Yes❑ Nod( If Yes,Explain:
Please Fill In The Following Information About The New Dwelling: _
Type Of Dwelling: Number Of Bedrooms: Number Of People:
Requested By. �a Z BDate Requested: a. rD
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
.Comments:
2 i
Environmental Health Specialist Date
"The signing of this form by the Environmental Health 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 #• `
— _. . ENT
IMPROVEMENT AND.OPERATION PERMITS PROPERTY`INFORMATION
rzrmittee'5 ,�,,
Name: Subdivision Name:
Directions to property: :' - J. > = .r �', . Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
4 Pddress Na6a L(,(/) 0 l>? WAS-30/x . kJ • ,
"[ / Road Name , - .J ` j i" Zlpt fp, :X
**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 G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE L /-� #BEDROOMS,—,s? #BATHS V #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) fr(1 NEW SITE REPAIR SITE !—
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH �%' ROCK DEPTH ? LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDPPIONS:
IMPROVEMENT PERMIT LAYOUT
1v
**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: i!f ! Jl�✓ I. �r
t
AUTHORIZATION NO. �+� f OPERATION PERMIT BY: "•,f N s` DATE:
x
**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 05/96(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
Account #: Tax PIN/EH#:
Billed To: Subdivision Info:
Reference Name: Location/Address:
Proposed Facility: Property Size: Date Evaluated: ll�dS'
Water Supply: On-Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope% 0
HORIZON I DEPTH l
Texture groupGG
Consistence
Structure l
Mineralogy '
HORIZON II DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture Eroup
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE x
SITE CLASSIFICATION: EVALUATION BY: ' �c
LONG-TERM ACCEPTANCE RATE: OTHER(S)PRESENT:
REMARKS:
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 511-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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1057
AUTHORIZATIONNO: DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee'sP.O.Box 848
Name: n !"t4Mocksville,NC 27028 Subdivision Name:
Phone#:704-634-8760
Directions to property _1� r
7 e f r'-�."✓a � Section: Lot:
AUTHORIZATION FOR
WASTEWATER. - Tax Office PIN:# - -
SYSTEM CONSTRUCTION. OV ,
Name��""�/�/ 6,,Q4118 'A F
P:�
**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 FormlAuthorization 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)
/ M ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
' / '�'• IS VALID FOR A PERIOD OF FIVE YEARS.
EN'IRONMENTAL HEAL4fi SPECIALIST DATE ISSUED,
�'•r+_ ♦ `a r ti a i1'" i, a:- 1 a .., � .., - �t - _ `
10 DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
`perinittee�'� J
Name: }/J= r '��'" °ts r.i Subdivision Name:
Directions to peoperty"_ r/;j'�%/,'f,' �' ,2' t yj Section: Lot:
IMPROVEMENT
;` ` ,• PERMIT Tax Office PIN:#
Ro..., ��77 ,r f
ad NameC�NIK t✓—IQ 111/4 f t �Q
**NOTE_**This Improvement Permit"DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.�n
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior.to the
constructionlmstallation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
i ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE A jAi___ #BEDROOM _P #BATHS V_#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 !i"
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH _ ROCK DEPTH n LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
r�
**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: /�/ s
"ZL
E:
AUTHORIZATION NO.--� i OPERATION PERMIT BY:-----7 .� DATE: GJ/
**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 TRAE.
DCHD 05/96(Revised)
DAVIE COUNTY HEALTH DEPARTMENT
D
NT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
PErrnittee s
Name: Subdivision Name:
Directions to property:- Section: Lot:
e IMPROVEMENT
.,/ PERMIT Tax Office PIN:#
r � r
Rd N et f-r A(=(-' "�f Zip`
E
**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/ristallation of a system or the issuance of a building permit.
(In compliance with Article 11 of G.S.Chapter 13QA,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
`s
RESIDENTIAL SPECIFICATION:BUILDING TYPE ,/ #BEDROOMS' #BATHS #OCCUPANTS GARBAGE DISPOSAL:Yes or'No-
COMMERCIAL SPECIFICATION: FACILITY TYPE, , #PEOPLE #PEOPLEtSHIFT #SEATS INDUSTRIAL WASTE:Yes or No
,
s
LOT SIZE TYPE WATER SUPPLY } DESIGN WASTEWATER FLOW(GPD) 6 NEW SITE REPAIR SITE L✓
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH '/ ROCK DEPTH / ' LINEAR FT. /dy�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
or
**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:
XV-10
AUTHORIZATION NO. A OPERATION PERMIT BY: DATE: G
**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 05/96(Revised)
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT
NAME Sifiryef ¢410,oy PHONE NUMBER
ADDRESS SUBDIVISION NAME
i
SUBDIVISION LOT#
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED
NAME SYSTEM INSTALLED UNDER
SPECIFY PROBLEMS OCCURRING
DATE REQUESTED INFORMATION TAKEN BY