775 Cherry Hill Rd AUTHC�yZ' ATION NO: 1675 DAVIE OOUNTY HEALTH DEPARTMENT 3
r - Environmental Health Section PROPERTY INFORMATION -q
Permitfee's P.O.Box 848 �Q i
Name: L
� /lin Mocksville,NC 27028 Subdivision Name: y"
Phone# 336-751-8760
Directions to property: 7.r �r� ' Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:# —7
SYSTEM CONSTRUCTION
Road Name: tp: 0
**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) I
/ � ***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
V15 �O/� d' IS VALID FOR A PERIOD OF FIVE YEARS:
ENV[ ONMENTAL HEALTH SPECIALIST DATE ISSUED
J
RESIDENTIAL SPECIFICATION:BUILDING TYPE �2L#BATHS_/—#OCCUPANTS IL�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--Z REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE DDD GAL. PUMP TANK GAL. TRENCH WIDTH.� ROCK DEPTH 1,0 LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
i
t
� L✓ , fro,,•
I
i
I
"CONTACT A REPRESENTATIVE OF THE bAVIE 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 I
SYSTEM INSTALLED BY:
i
L7
i
i
I
Ib� tba
AUTHORIZATION NO. 0-!—r
OPERAT10N 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 A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
IKHD 05/96(Revised)
Davie County, NC Tax Parcel Report Monday, September 26, 2016
7,45
5'54�5 415,t`
t i
C)
Ct !211
7
1
780
7782 -
5
5515� 711
WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number: M60000005304 Township: Jerusalem
NCPIN Number: 5755864526 Municipality:
Account Number: 82524570 Census Tract: 37059-807
Listed Owner 1: CLENDENIN JAMES A ETAL Voting Precinct: JERUSALEM
Mailing Address 1: 673 DEADMON ROAD Planning Jurisdiction: Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A
State: NC Zoning Overlay:
Zip Code: 27028-0000 Voluntary Ag.District: No
Legal Description: 3.741 AC CHERRY HILL RD Fire Response District: JERUSALEM
Assessed Acreage: 3.67 Elementary School Zone: COOLEEMEE
Deed Date: 6/2005 Middle School Zone: SOUTH DAVIE
Deed Book/Page: 006110097 Soil Types: PcB2,PcC2
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 0.00 Outbuilding 8r Extra 14490.00
Freatures Value:
Land Value: 31640.00 Total Market Value: 46130.00
Total Assessed Value: 46130.00
161
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 harmlessthe
NC County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to
or arising out of the use or Inability to use the GIS data provided by this webahe.
' AOTIIORI4:ATION NO 162
DAVID COUNTY HEALTH DEPARTMENT
'
'.Environmental Health Section PROPERTY INFORMATION
Permittee Yti , P.O;Box 848
Name: �J Pe2t/ r ��1/`r!'t'1�4 Mocksville,NC 27028 .Subdivision Name:
n -7 -8760
Phone# 336` 51
Directions to property: _f 1 ,// Section:' Lot:
AUTHORIZATION FOR
r WASTEWATER Tax Office PIN:#f SYSTEM CONSTRUCTION _ - -
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.1900 Sewage Treatment and Disposal Systems)
***NOTICE***.THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTYMPECIALIST DATE ISSUED
. l ':v_7 y i.- ..ti `. �;",.. N. .. s ;'v'• � 'I r,S. . -. -.. .. - _ r .,, . .,_.,.. t/•�.......-� 7�4a�:s-rt.
TY HEALTH DE AR 'M
621 A DAVIE COITN H �33 T NT
TMPROVE ENT'AND OPERATIOMPERMITS PROPERTY INFORMATION
�•PermlKtet's
Name:{ s t� r'r �' Subdivision Name:
Directions to property: 1 .7 �:��'�::. �,�i} Section: Lot:
~* IMPROVEMENT,
PERMIT Tax Office PIN:# - -
Road Name: Zip:
**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 HEAL SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE,QZ #BEDROOMS, #BATHS�,_#OCCUPANTS 2. GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE #PEOPLE/SHIFr #SEATS INDUSTRIAL WASTE:Yes or No
LOT SIZE TYPE WATER SUPPLY Alle DESIGN WASTEWATER FLOW(GPD) �?gy NEW SITE� , REPAIR SITE 4'
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH -?6 ROCK DEPTH 1 LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT *APPROVED EFFLUENT FILTER* *RISER(S) IF 6" BELOW FINISHED GRADE
16 77\4
**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(7iS4'j 7634IV16W X
(336)751-8760
OPERATION PERMITL�/-�"
SYSTEM INSTALLED BY: k
K.
/ ���ISTIrJb
41�°
/
AUTHORIZATION NO. Q OPERATION PERMIT BY: �
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABO S 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)
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` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
Soil/Site Evaluation
APPLICANT'S NAME ?/ZA DATE EVALUATED
PROPOSED FACILITY PROPERTY SIZE
SUBDIVISION ROAD NAME
Water Supply: On-Site Well ✓ Community Public
Evaluation By: Auger Boring 1Z Pit Cut
FACTORS 1 2 3 4 5 6 7
Landscape position
Slope%
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence i
Structure
Mineralogy '
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLTTE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE -7-
SITE CLASSIFICATION: EVALUATION BY:
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 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
DCHD(01-90)
7 �.,.�.; rt{•1;s.y:, _ ..�3p�..,;^}ii,�.<i'. r tr.:. ♦+.':: ham .. r ..•e:. k4 -.,_., ....,..-�',,.. -.-�� Rf'+,
DAVIE COUNTY HEALTH DEPARTM NT
J R
IMPROVETENT AND OPERATION PERMJTS PROPERTY INFORMATION
_ PermitteeIg ,'s , 6
Name: «�' �" f r' Subdivision Name:
Y �
Directions to property: .'t' :{,"r l: :: Section: Lot:
IMPROVEMENT
PERMIT' Tax Office PIN:#
Road Name: Zip:
**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&# #BEDROOMS -P #..BATHS #OCCUPANTS :2— GARBAGE DISPOSAL:Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE #PEOPLE ' #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes
or No
LOT SIZE/ ,r TYPE WATER SUPPLY r�� DESIGN WASTEWATER FLOW(GPD) ✓ NEW SITE REPAIR SITE N'
SYSTEM SPECIFICATIONS: TANK SIZE/ GAL. PUMP TANK GAL. TRENCH WIDTH J i6 ROCK DEPTH /.I• LINEAR FT. f
OTHER ;
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT �AppREIVED EFFLUM-a FILTER* *RISER(S) IF 6*' DEL{lfil FINISHED GRADE*
**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(7"W-1W X
(336)751-8760
OPERATION PERMIT , 1 ~�
SYSTEM INSTALLED BY:
=WC-
I
T
� t
AUTHORIZATION NO. 'L OPERATION PERMIT BY: b
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED AB 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 ,
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENTX REMODELING ❑ RECONNECTION ❑
Name: WD Y L S /� e,)i G1 y-) ) Phone Number: L—��?— �/ / (Home)
Mailing Address: r7 1 1+ Lh e YV/ 4111 K ��4 r_n, (Work)
ho o r_'&S J j 1)P � IVC_ "2M2 a 9
Detailed Directions To Site: 7-vi V_ 1,61 ,;;bo 6- - ) I�IA.,*es_T vo La-a
Property Address: _c- �e x iey 1401 19J ,
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under: :.e.l c r t.S d-e v1 at i,\ i WType of Dwelling: l 0 el
Date System Installed(Month/Day/Year): Number Of Bedrooms: _Number Of People:,_
Is The Dwelling Currently Vacant? Yes❑ NoX If Yes,For How Long?
Any Known Problems?Yes❑ No)( If Yes,Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling:,m D b Jt i 01 Yl P_ Number Of Bedrooms: 13 Number Of People: _
Requested By: PI&X4Date Requested: a-�" 9
(Signature)
For Environmental Health Office Use Only
Approved ❑ Disapproved ❑
Comments: �C / /� A d roe X 3 x/ 5e e 42 e1/n i VJ 7'
Environmental Health Specialist X27 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 #: ��
.t /k/
4 : DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section /
Mocksville,NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENTX REMODELING ❑ RECONNECTION ❑
Name: ne,f 0 Y e S ("&17 1�'e in 1 yl Phone Number: 36--6-j!M- (Home)
Mailing Address: 915 CJ h e y ry 4 0 1R� Zr2ia t�!_ . (Work)
rn t)C,k!S C) i I )(01iV L
Detailed Directions To Site: Etna () I ,�±Q Llr)V II C C S 4 y w L. ,:Ct
Property Address:
Please Fill In The Following Information About The Existing Dwelling:
Name System Installed Under: De-h o r c S 0-en c i jAi ry Type Of Dwelling: n
Date System Installed(Month/Day/Year): Number Of Bedrooms: Number Of People:
Is The Dwelling Currently Vacant? Yes❑ No)l If Yes,For How Long?
Any Known Problems?Yes❑ NoX If Yes,Explain:
Please Fill In The Following Information About The New Dwelling:
Type Of Dwelling:M 0101),_k DrA e„ Number k Bedrooms: Number Of People:
Requested By: 1it�t�t�rti' Date Requested:
(Signature)
For Environmexital Health Office Use Only
Approved ❑ Disapproved ❑ /
Comments
r
Environmental Health Specialist Date—le�
*The signing of this form by the Environmental Health Staff is in no way intended", of siio M iie 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: t
�� e..
Account #: L Invoice.#:.