250 George Jones RdDavie County~ NC
Tax Parcel Report d V 1 b Thursday, September 29, 2016
<. P arc6l In ormation
A
Parcel Number:
160000001301
Township:
Shady Grove
NCPIN Number:
5758698329
Municipality:
Account Number:
17078620
Census Tract:
37059-804
Listed Owner 1:
COOPER VURRALL DELTON III
Voting Precinct:
WEST SHADY GROVE
Mailing Address 1:
250 GEORGE JONES 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:
3.022 AC OFF CORNATZER RD
Fire Response District:
CORNATZER - DULIN
Assessed Acreage:
3.02
Elementary School Zone:
CORNATZER
Deed Date:
/
Middle School Zone:
WILLIAM ELLIS
Deed Book / Page:
Soil Types:
RnC,RnD
Plat Book:
11
Flood Zone:
Plat Page:
310
Watershed Overlay:
DAVIE COUNTY
Building Value:
122440.00
Outbuilding & Extra
4680.00
Freatures Value:
Land Value:
27330.00
Total Market Value:
154450.00
Total Assessed Value:
154450.00
Davie County,
�T
l� C
All data Is providedas Is without warranty or guarantee of any kind either expressed or Implied including but not limited to the
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.
rQ'rr,.-ve2r., t+="x Hra� ='s r�;..t � .,'..;Rrt.,e�i�ryk ri{;,:`K 4: i'F'ae*.F�'P r;t;qui �'`"�• r4'E-;Yrs ,�, '4 'ai�7.'.- J�iti .+'.3 Yrr 'rr :ii'. _^.� 4�}�` � �J�.-a: sa�
AUTHORIZATION NO: Q 6 78 DAVIE COUNTY HEALTH DEPARTMENT -I �a
Environmental Health Section PROPERTY INFORMATION
Permittees' P.O. Box 848
Name:— I Mocksville, NC 27028 Subdivision Name: -
� r f Phone #: 704-634-8760
Directions to property: Ci"� L1' f l"--"f!�`'"/' Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Offi e PIN:#:»�0
SYSTEM CONSTRUCTION; e�
Road �Zip:
**NOTE** This Authorization for Wastewater System Construction MUST BE ISSUED by 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
.�rGG'� f1' rrr J ✓i/ �J�C IS VALID FOR APERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE I,SSUED
t4f'7.ywa " ,Mi•..i ti } >'o,.,:r' t.� 97 i1 i. j•'sa J7.+' r,
DAVIE COUNTY HEALTH DEP IT, 9 3a
IMPROVEMENT AND OPERATION P99MITS PROPERTY INFORMATION
,,., c�;a . • Vit;.
Periiutee's
N;me: Subdivision Name:
Directions to property: : <.'tt . `l Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#,,P-
Road Name �Y t} k't ,. 7i 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 # BATHS - # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE S�rl� TYPE WATER SUPPLY Ille // DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE /ffiGAL. PUMP TANK GAL. TRENCH WIDTH,?,/, ROCK DEPTH LINEAR FT.�„�
OTHER –
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 (704) 634-8760.
OPERATION PERMIT `
SYSTEM INSTALLED Y:
" fi
c �
M <
.2=
6-
-----------
SYSTEM
�L
- G
N.
J45
AUTHORIZATION NOMM A D OPERATION PERMIT BY: DATE:
"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)
o �A� -�
APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERM a V E
V(� Davie County Health Department
Environmental Health Section
(7� ; P O. Box 848 FEB - 41997
Mocksville, NC 27028
(704)634-8760
�1
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCES�ED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
n �-
1. Name to be Billed ! r, 9191 Z- f�• C- D D 1% %f � Contact Person - /a �
Mailing AddressHome Phone /
City/State/Zip Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address A City/State/Zip
3. Application For: bite Evaluation ❑ Improvement Permit & ATC Both
4. System to Serve: W- house ❑ Mobile Home ❑ Business ❑ Industry ❑ Other
5. If Residence: # People 3 # Bedrooms _ # Bathrooms f
016ishwasher ❑ Garbage Disposal 8-'—W—ashing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type # People # Sinks
# Commodes # Showers # Urinals # Water Coolers
If Foodservice: # Seats Estimated Water Usage (gallons per day)
7. Type of water supply: ❑ County/City Z -Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes 61—No
If yes, what type?
INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION. .
Property Dimensions: oc lqC
Tax Office PIN: # / S O - & 9 - a
Property Address: Road Name c-2 So Q SOJ✓e5
city/zip /YIo ,�' S!/. `J Je D /• C
If in Subdivision provide information, as follows:
Name:
Section:
Lot #:
WRITE DIRECTIONS (from
Mocksville) TO PROPERTY:
'e Cf 0 / C.01W,'H2 X */
�rA%
4-a FAl rl AY,z,L r L,- -Af-
'-.ave /
This is to certify that the information provided is correct to the best of my knowledge. I understand that any permit(s) issued hereafter
are 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 L i/I/& -19A eS (-OOR Z !/G���`f�� L 4&er-V to conduct all testing procedures
as necessary to determine the site suitability.
DATESIGNATURE
Revised DCHD (06-96)
•'cJ.
-AI-
i d77
+Ig
si ,; n p s, 62,990
i ro X 4
'4711,
_ fi� - ° • F '� „` rQl .p `, �; ,.e t s &44t > ,� arts ` ei ,
k€ + " s,� c n a"r; ` a aw •' Ci' C'`vhi'ar " �1* "Z'40
rxy».��7 ,' , p ,� fl
cq
sh .� f 'V; •� N �.0 a�.yy{{�� `/tel W i k
IV^: d T s ZA e'� r x,x r � ' , "figsaaA
y A, f a�
140)
it`s".-, � w: � W 8 �` p d i .A� t Yf` >�x�3 Y �°g :� £ f '✓
,� �, /gyp �! Lam} • y,��/{y� g h
9 61N� sPi n ,+ ykb tea. T i J� l� 33MF' #T i N �Cy Y Y
! i OD
117-
4t
Cb
,`Sy _ \ f ���� £LN ` �� .Y,.,�p$.A K.r • r'� b � r,Y. w�+�"�." ' u � �A�+ ��, � �M��y
t .s'J` } K "1, � N �' ,� � n �t ��Q "f"*,° x y'` � .'""et �. , }.�n f• ;a"" � 1"
1(XO4
i l} g• $ � 32"1 � 4 � ��Y *x ,� d � ,�+{ �, 9�a. 7 ,°�` ,��,�
' \\ ,_ I �••' O 1��' "� �y.. 'T.. c�6 ,(Y awi �.. x' M A':: �� i�y r� r � ;��' �xn S✓',�,' _ „ �i
'o,
Yet j �. � �° � r •�
792 "r '
ch"
i 0)
N r i e �,ay 06b
S ,i li' S<zi h�J
qx
�\� � y�'t�µT�� "fit "`�a.. vat'„�`�'�•��.�r �"�*'p# T m '„��,, '1 � t 4'r...'� }.� ,p � 's
Dfit
Of,
4+44.
O Q tt7 ,y'� 7j vt t i w�m ra Yro+y'
4
r+ 1
1060
t . • - TkS b „.` t Y 'F'�� s y"}`F t.X Fl {' 1SF'1. •,
q�
'1
_k
•�
fr
4--
Je.h 44"
5 '_T
Al
f
1
f y
'
4
�9
�K
t
Wl
Oj
n
3
i d77
+Ig
si ,; n p s, 62,990
i ro X 4
'4711,
_ fi� - ° • F '� „` rQl .p `, �; ,.e t s &44t > ,� arts ` ei ,
k€ + " s,� c n a"r; ` a aw •' Ci' C'`vhi'ar " �1* "Z'40
rxy».��7 ,' , p ,� fl
cq
sh .� f 'V; •� N �.0 a�.yy{{�� `/tel W i k
IV^: d T s ZA e'� r x,x r � ' , "figsaaA
y A, f a�
140)
it`s".-, � w: � W 8 �` p d i .A� t Yf` >�x�3 Y �°g :� £ f '✓
,� �, /gyp �! Lam} • y,��/{y� g h
9 61N� sPi n ,+ ykb tea. T i J� l� 33MF' #T i N �Cy Y Y
! i OD
117-
4t
Cb
,`Sy _ \ f ���� £LN ` �� .Y,.,�p$.A K.r • r'� b � r,Y. w�+�"�." ' u � �A�+ ��, � �M��y
t .s'J` } K "1, � N �' ,� � n �t ��Q "f"*,° x y'` � .'""et �. , }.�n f• ;a"" � 1"
1(XO4
i l} g• $ � 32"1 � 4 � ��Y *x ,� d � ,�+{ �, 9�a. 7 ,°�` ,��,�
' \\ ,_ I �••' O 1��' "� �y.. 'T.. c�6 ,(Y awi �.. x' M A':: �� i�y r� r � ;��' �xn S✓',�,' _ „ �i
'o,
Yet j �. � �° � r •�
792 "r '
ch"
i 0)
N r i e �,ay 06b
S ,i li' S<zi h�J
qx
�\� � y�'t�µT�� "fit "`�a.. vat'„�`�'�•��.�r �"�*'p# T m '„��,, '1 � t 4'r...'� }.� ,p � 's
Dfit
Of,
4+44.
O Q tt7 ,y'� 7j vt t i w�m ra Yro+y'
4
r+ 1
1060
t . • - TkS b „.` t Y 'F'�� s y"}`F t.X Fl {' 1SF'1. •,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section SECTION LOT
µ Soil/Site Evaluation
APPLICANT'S NAME ' 1N DATE EVALUATED
PROPOSED FACILITY ! IT PROPERTY SIZE/
SUBDIVISION ROAD NAME—
Water Supply: On -Site Well c/
Community
Evaluation By: . Auger Boring Pit
Public
Cut
FACTORS
1
2 3 4 5 6 7
Landscape position
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
D F
6 �-
Texture group
Consistence
r
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION:
t
LONG-TERM ACCEPTANCE RATE:
REMARKS:
DCHD (01-90)
EVALUATION BY: &4Z
OTHER(S) PRESENT:
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
SOME
■■■■
■E■■
NONE
MEMO
■■MM■MM■■MMN■■■■MMN■
■■ME■EMM■■E■ME■EM■■■
■■ME■EMS■ME■■EM■ ■■
■■MN■M■MM■■■■■■M�■■
■■MEMS■MEM■■E■EMEN■■
■MM■Mm■■MM■■M■MEMMM■
■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■ ■■
■■■■■■■■■■■■■■■■ ■■
■■■■■■■■■■■■■■■■■■■■
■■■■E■■■■■■■■■■■■■■■
■■■■■MEN■■■Mmn■■■■■■
■E■■■■NN■■■M■N■■■■E■
■■■■M■NE■■MN■■■■■E■■
■■■■■■■■■■M■■■■■■■■■
■■■MEMEMEMEMEMENU■■
■■■■■■■■■■■■■■■■ on
■NN■N■■■■■■■■M■■■■■■
■■■■■■■M■■■■m■M■■■■■
■■■■■■■M■■■M■E■■■■■■
■■■■■■■■■■■■■■■■■■■■
■■■■n■■■■■E■■M■■■■■■
■■■■■■M■■■E■■■■■■■■■
■■■■■E■■■■■■■■■■ ■■
■■■■■■EN■■■■■■■■�■■
■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■
MEME
■■�i
MEMO
NONE
■■M■
MEMO
■E■■
so
ME
■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■
■■■■■■■■■■■■■■■■■■■■■■■
■M■■■
■N■■■
■■■■■
■E■■■■EMEN■■
■■■■■■■■E■■■
■■M■NM■■N■■■
■■■■■■■■■■■■
■■■■■■■■■■■■
■MM■■■■■■■M■
■■■■■■■■■■■■
■NE■■■MM■■E■
■■■■E■EEM■■■
■■■■M■■■N■■■
■■E■■EE■■■E■
■■■■■■■■■■■■
■■N■■■■■■■■■
■■■■■■■■■■■■
■N■■■■■■■N■■
■■■■■■■■■
■■■■■■
■N■■■■
■■■■■■
■■■■n■
■■NEEM
■■MONS
MEMO■■
■N■■E■
■■■■■■■■■■■■
■NEEM■■■■■E■
■N■■■N■■EMN■
■■■■■■■■■■■■
■■■■■■■■■M■■
■■■■M■■■M■■■
■EEN■■■■N■■■
■■■■■■■■■■■■
■■■■■■NM■■■■
.. .:;,�;dww ,.a:f t+r'�{�kr "t��s.�.4�iM;4"twv+�r r„w..x.�?ea i1t" rti?-iX .k` .^v:4t ,..r..w .�a�'�.G., ii `�::yv,+t� 'M � a.:t+z. �, -.. �nt•...
.-+ ,�7iF , r- f k., �.,.;.
. ' � " . � , . ; _ .s"=d�"�d µ �=�::��; � � �,� �
,. ..
�� .
AUTHORIZqTION NO: ����Af DAVIE COUNTY HEALTH DEPART ENT �.---�--�-=t-t :�,
�� � : , �
`�; ,, Environmental Health Section � PROPERTY, INFORMATION
Permittee ti -,',^`,� ,-�. P.O. Box 848
� Name: � � � L-� �"?"'����"" 'Mocksville, NC 27028 , Subdivision Name: �
� Phone # 336-751-8760
Directions to property; •� f�� lr '��'c� �•., Section: : Lot:
, r � AUTHORIZATION FOR :
�^ � � WASTEWATER
t.,,.�L�`�'./� � e� �;,�.., ���.- )C,7 tJ Tax Office PIN:# -
SYSTFM CONSTRUCTION -;
� /� �� 4
�.� � r�
C�;;-�l;Ci��.��. � �ty ���.5 ' �i�' Road Namet:�X: � ��'��p. _'� �;,�
.
� **NOTE** This Authorizat►on for Wastewater System Construction MUST,BE ;ISSUED by the Davie County Envuonmental Health Section prior
to issuance of: any Building-PernvtS. This: Forni/Authonzauon Number should be presented to the Davie Counry Building Inspections
Office when applying for Building Permits.' �. . : '
(in compliance�with Anicle 11 , f G.S. Chapter 130A; Wastewater Systems Section .1900 Sewage Treatment and Disposal Systems)
, :, -;,.�� , a,, . , .. . ,_. . ; ,
� ' —� *** TICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION �
NO
,_„�,�., ��;y;, ,� � IS VALm FOR A PERIOD OF FTVE YEARS.
ENVIRONIvIEr TAL HEALTH SPE IA�IST': .. D r E SSUED ' k �
ti
i
1:745/1DAVIE, COUNTY HEALTH DEPARTMENT;0
'�. JMPROEMENT AND OPERATION PERMITS PROPERTY INFORMATION
. Permittee's;'� �>
Name: 1 i_ �'- "� �=" Subdivision Name:
Directions to property: . L L t Section: Lot:
' IMPROVEMENT
r r..r r*\ ! 4 }s: , f..: ,: •.� PERMIT Tax Office PIN:# _
*4-1
Road Name t , i . p r= tp !: �k
**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 I l of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
w r' ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
-.. ,r . % :. / }., . `�— .'',r 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 tj OLT> # BEDROOMS 3— # BATHS 2 # OCCUPANTS �`r GARBAGE DISPOSAL: Yes o No
COMMERCIAL SPECIFICATION: FACILITY,TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE"'- TYPE WATER SUPPLY CCL. DESIGN WASTEWATER FLOW (GPD)�C NEW SITE REPAIR SITE
- t 'r
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH I L. LINEAR Fr. 301)
OTHER
A v,� C-OA-rot)4 CCUT oFF tr )(IST,
REQUIRED SITE MO IFICATIONS/CONDITIONS: fJ SY L 1.. � A& 1 L1.t L t._ �cS
IMPROVEMENT PERMIT LAYOUT
*APPROVED LlENT FILTER* *RISER(S) IF 611 BELOW FINISHED GRADE*.
7 J
t,x1Z I
*"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.
XXXXXHHXH
OPERATION PERMIT
z
SYSTEM INSTALLED BY: �^� 7 W*I t'iA ►LIZ
�T
IaAov
" a �oosS
a
s�
0
12,L� K13
1 �,�,
AUTHORIZATION NO. I "'r" ' OPERATION PERMIT B . DATE:
"*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBEDOVE HAS BEEN INSTALLED IN IOMPLIANCE
WITH ARTICLE i 1 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)
Accr��
o.�:_,,,i:e �. •sy �. i'i iiY ^�.yJ., Z,'t7''_-�'�^t"..y
-54 DAME . OUNTY HEALTH DEP AR ENT
i IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permlttee's
Name: L `` �� " Subdivision Name:
Directions to property: ` ''i k� Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#
- r..
A `
1. Road Name: . t:- �f r
L Zi
**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)
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE
PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE l- 'r . # BEDROOMS, _ # BATHS # OCCUPANTS "-' _ GARBAGE DISPOSAL: Yes oe,o)
COMMERCCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE�—el �LI LTYPE WATER SUPPLY(AjLj - DESIGN WASTEWATER FLOW (GPD)7si L1 Q NEW SITE.—REPAIR SITE
r ,
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH I L? LINEAR FT.?e,t,
OTHER (�h,Q�l• 1.t T( 161)TIC a lxY
r
REQUIRED SITE M ODIFICATIONS/CONDITIONS: ��-)I ALL. U..1t
C&Al Ut� l i:.IVZ t>FF t X1 ST"�n1C^ `1 n1( L t ,�
fi
"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.
XXXXXXXXX
OPERATION PERMIT
r4 T-
r}a�ss
SYSTEM INSTALLED BY: 1 W+� ITA 1� ►yam
3�
g- sc��y�iTg
a
C>
I t�3
x
C,04. PL, LT
DA
/—j spa
C
X
AUTHORIZATION NO. OPERATION PERMIT B i DATE:
"THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED INOMPLIANCE
WITH ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96 (Revised)
y�� d
AiJTHQWATION NO: Q 6 7 8 DAVIE COUNTY HEALTH DEPARTMENT q ►y ��
Environmental Health.Section'',. ` PROPERTY INFORMATION '.
Permi[tee's P.O. Box 848
Nam--.Mocksville, NC 27028 .'_'Subdivision Name: - -
r r ln+ !f % Phone #: 704-634-8760
'Directions to property: �c"c3 Section Lot:'
AU i'HORIZATION FOR Q• !�
WASTEWATER Tax Offi PINI
SYSTEM CONSTRUCTION
e a�
Road Name:.Zip:
R $
**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.Buildu�g 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) 4' "N'0.
'
***NOTICE*** TEAS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED 7 i 4 ^ i } • ` s ' I „� (kt� ►'' �+ * ' k t r� �'
e.
RESIDENTIAL SPECIFICATION BUILDING TYPE # BEDROOMS S„�_ # BATH5� iI OCC[Jl'AN IS 4 < GARBAGE DISPOSAL. Yei o
f 1 t y f �: -. t• 7
777
���rilty:,gr.+rr�, y s....: «L.e.ry.+..c,....x+ � t . +i ��.� [ � t � • + ;
COMMERCIAL SPECIFICATION PACILITY TYPE # PEOPLE : M PEGPLElSi1>P1`: x # SEATS y _ `. INIIUSTRIAL WA$T$. a br oto t
LOT S12E %L� TYPE WATER SUPPLY Me Z/ DESIGN WASTEWATER FLOW (GPD) _ y +y ' 4Ea! S `REPAIR STfB
'.!�' 1'i ,:�( xy '. , ei � i1 '. .: . :$ .:.� i `� S 4Ar iY �'i..°"'t x 1!.ttiFit�h'tt�� ,' �..;�. p-:;�t �rxr •: x ,.a ,
SYSTEM SPECIFICATIONS: TANK SIZE 1�_GAL. , PUMP TANK GAL..' TRENCH WIDTH +r ROCK DEPTH,_ LII.AIL FT. ��� '
V 117010 . a+1 ,s - t (•„r
at ly r. a r ;:; � ;..�x'�S �.i1.<7, �i1I}�iej� .'«r( l✓,t�«ifrxLrLl�,;ii� ti i"t.,I�Y i + •
REQUB3ED Sri
E MODIFICAmomiCOmmoNS:
IMPROVEMENT PERM LAYOUT
i�e 1f,i •17 Y�' l�d'"Y9 t « �,.t;w .y r.�
{
. Af :.... r: ,.. ,. ,-r ,'..R d .;p-+ yr Y'+r.Y¢><+eWwd.Mr/><Fn -+tier T r*'+r,+ w "r!•1 t. .w;p+nr! +i ii d r e
'. . i1r.�'�
�1 tl'Zly' i .' ✓� G K�l'N�g} � C 7 iA 1 r
2
9' i ' ' :... 7-s �i'E4��,S'►`.�$C� �1 �I'�rA���tJiF� z y� �iS � r '
Y f
I
t' -
l' ^
OPERATION PERMIT %#c' (•. r re x , '
K SYSTEM INSTALLED Y a
AI
�
tat
a, a ... . . -r �., n ... ... � .. �:.. ., xi Y .w 1f4'� a �•� .v� +w.rna n p n;.t,+. Fn,l+ati.�iQ Ji .y .Ksa 4. Witv,.eid..perye.Y^w'w:+�r• +u,.,Ni..>a.,wrrw w:..a+Sr. t tw.. t:q g C
• i �"' i{ � t '+�, lai'}f i5xh ; x.t .rifr'�i'it''�iUS?<I i'4 �tCY} tH'iis +� y i,'1
'z t is • . � � •NQ ��\•' .Y, ,+;` :rr at�'�iti�kl�'� J3'3;i �t *�� 1; �.f+ sate )xE'Fa• f.`i'ti1`�f t.* ISs
' � t•, � .ri;'i I ; 5,r1,.? �" C Y�,�.rC`si.....r•:,.«tir t.�i'L"' t Z c:i �i" Y. I' . i a('il"`' t•'
• p � �r
AUTHORIZATION NO. V� D :' . OPERATION PERM BY. DATE v " - •
**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 130Ai SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NOWAY BETAKEN AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME
D= 05M (Reviled)