595 Cornatzer Rdrl—i. r^rv,nh, nin 4 Tay Pnrcal Rannrt a -1 14 1'l Toiccr1nv Confomhar 97 9n1R
77-7
Par6etinfortriafion
Parcel Number:
1600000075
Township:
Shady Grove
NCPIN Number:
5758657147
Municipality:
Account Number:
58084000
Census Tract:
37059-804
Listed Owner 1:
POTTS LUTHER B
Voting Precinct:
WEST SHADY GROVE
Mailing Address 1:
PO BOX 262
Planning Jurisdiction:
Davie County
City:
MOCKSVILLE
Zoning Class:
DAVIE COUNTY R-A,R-20
State:
NC
Zoning Overlay:
Zip Code:
27028-0000
Voluntary Ag. District:
No
Legal Description:
LOTS 37-39 P/O 40-41 SPENCER
Fire Response District:
CORNATZER - DULIN
HANES
Assessed Acreage:
2.21
Elementary School Zone:
CORNATZER
Deed Date:
2/1971
Middle School Zone:
WILLIAM ELLIS
Deed Book f Page:
000830457
Soil Types:
GnB2,RnC
Plat Book:
0002
Flood Zone:
X
Plat Page:
065
Watershed Overlay:
-
Building Value:
72720.00
Outbuilding & Extra
3100.00
Freatures Value:
Land Value:
39750.00
Total Market Value:
115570.00
Total Assessed Value:
115570.00
il
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Davie County, NC 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 or arising out of the use or inability to use the GIS data provided by this website.
;) DAVIE COUNTY HEALTH DEPARTMENT !o� /lv� % ,o
�" M_
Name: , ✓ + "'� '7X, Environmental Health Section PROPERTY INFORMATION
P.O. Box 848
"Directions to property: C r�� 1 �� .J yt"� � Mocksville, NC 21028 Subdivision Name:
Phone #: 336-751-8760
,rTS� a1 Section: Lot:
AUTHORIZATION; FOR
WASTEWATER' Tax Office PIN:# - -
I l �r ✓` SYSTEM CONSTRUCTION
AUTHORIZATION NO: A 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.
i
(In compliance with Article I 1 ;of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
l
x„g ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
IS VALID FOR A PERIOD OF FIVE YEARS.,
ENVIRONMENTAL HEALTH S E . LIST 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 SIZE GAL. PUMP TANK GAL TRENCH WIDTH ROCK DEPTH IINEAR FT. a?`-
OTHER
L�
REQUIRED SITE MODIFICATIONS/CONDITIONS:
"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 (336)751-8760.
I)CFiD 0202 (Revised) - -44-4 -2
V'� J 7-7 ° .
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
PO Box 848/210 Hospital Street
Mocksville, NC 27028
Phone: (336)751-8760
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) REPLACEMENT ❑ REMODELING ❑ RECONNECTION ❑
Detailed Directions To Site:
Number: (Home)
(Work)
Property Address:—j r �' l/1 r1
Please Fill In The Following Information About The Existing Dwelling.
Name System Installed Under: - ----Type Of Dwelling:
Date System Installed(Month/Day/Year):JvNumber Of Bedrooms---a—Number Of People:__
Is The Dwelling Currently Vacant? Yes ❑ No ❑ 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 Dwe ' g:WL��iQ Number Of Bedrooms: Number Of People:
09 7 F-8'335
Requested By: Date Requested:
(Signature) (0 7Y -/— 2 5' s-7
For Environmental Health Office Use Only
Approved Disapproved C
N
Environmental Health
M
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 #: