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2131 Hwy 601N`i'`i„ '� -ao- F.w--,�si�_: ,,� .� :,t s.r,�n✓..�, J.K„S.La.:FI> �' '�"`k ' 1;a .:#�..°`V � .� '\ 4�s9 e�."pi r. �x W�4'..�s .a t,d- vt: r ,,-ti '4 i''a�v...e '..r<+..v:. .. 4 �+ >`'ALS DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION �. permitea.s,yZ z Subdivision Name: Dgeqions�o perty: y i,x` f ' ` " 1"�/ `` f Section r Lot: IMPROVFMENT PERMIT Tax Office PIN: *� Road Na 1 ��# Zip: e r• ' **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 CONSTRPCTION must be obtai ied from this Department prior to the,. a ` construction/installation of a system or the issuance of a building permit. Vn 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 " L? E!. S '+� " �: :.-- +� PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER - NVIRONMENTAL HEALTHSPECIALIST 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 mE,F # PEOPLE # PEOPLF/SHIFT #SEATS INDUSTRIAL WASTE: Yes o /J dalr" LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE SYSTEM SPECIFICATIONS: TANK SIZE ZIM GAL: PUMP TANK GAL. TRENCH WIDTH1, 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 BY: y AUTHORIZATION NO. OPERATION PERMIT BY: DATE: v **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH ARTICLE 1 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. DCHD 05/96 (Revised) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit Requested By ' -J U '!1 2. Address q17- 3. 13. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption Home Phone T 9 Z" r2- 3 a Business Phone !2 12 -7Z-3 -Z6/0 Z✓ -- S . -Al_e_-Z710_Z c) �F.jb-Division Sec. Lot No. 5. System used -to serve what type facility: House Mobile Home Business IndustryOther b) Number of people 6. aj If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms Bath Rooms Den w/Closet b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) 7. Number and type of water -using fixtures: commodes urinals garbage disposal lavatory showers washing machine dishwasher sinks - 3 8. a) Type water supply: Public ✓ Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the est of my knowledge. Date Ow er Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL,LAWS Allow 5 days_for processing Directions to property: 4/n DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Health Department. 2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin." NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO: Davie County Health Department, Environmental Health Section, P. O..Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED (office use only) yes no 1. 1 am the owner of the above described property. yes no 2. 1 am not the owner of the above described property, however, I certify that I have consent from , owner to obtain a owner's name site evaluation by the Davie County Health Department for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. 1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon the above described property and conduct all testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: — Owner only Owners designated representative Anyone requesting results — Only those listed below DATE SIGNATURE DCHD (11 /84) W. G. WHITE & CO. RS IN . . . HEAVY AND FANCY GROCERIES - FRUITS AND VEGETABLES - WHOLESALE AND RET HOME OF COUNTRY HAMS & WHITE'S ALL -DAY COFFEE 642 N. CHERRY ST. PHONE 723-1669 P. O. BOX 37 WINSTON-SALEM, N. C. 1 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Size FAr`TnRC AREA 1 ARFA 9 AREA R AREA A I) Topography/ Landscape Position ! ©W <5S PS U PS U PS U PS U �) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) PS S U U U 3) Soil Structure (12-36 in.) Clayey Soils S S S U U U /U l) Soil Depth (inches) � _� P S U S U U i) Soil Drainage: Internal P U U U U External S (SS `CT S q�) S �`, U i) Restrictive Horizons Available Space S PS PS PS S PS U U U U 1) Other (Specify) S PS S PS S PS S PS U/ U U U i) Site Classification U—UNSUITABLE S—SUITABLE _ PS—Provisionally Suitable Recommendations/Comments: Described by �! / Title ��" Date SITE DIAGRAM n� UCHD (6-82) i� 1«asl� tA, - 1 w"i'1' moi.` �M>�^:a .y+, .. t�+a Y _ '.. ni � y:t fyw ..�t.Z..s.• - ..yL 1 AUTHORIZATION NO - Q- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permltiee's , � � P.O.'Box 848: hTa.�/�E' Mocksville, NC 27028 , Subd meivision Name: , �-. - — Phone #: 704-634-8760 • Directions to property: Section: Lot: AUTHORIZATION FOR . WASTEWATER CONSTRUCTION�J SYSTEM CONSTRUCTION Tax OfficePIN:# d - 0T Road Nam �. (€a d f' +� Zip: **NOTE**. This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior 'y 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. (Incompliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section a900 Sewage Treatment and Disposal Systems) .r rCJ' `/***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION ',%'�7) (i ;/ �� IS VALID FOR A PERIOD OF FIVE YEARS. , ENVIRONMENTAL HEALTH SPECIALIST Dq E ISSUED aW C: -,.: .^. .yw .w....- .._.. y,.r_y..d�....�.. .:aa..�.a".y'!. `.'2.�r-- .2-3s3: - �L.. � , /t': CI •S e t S . . .. - - r ... , ,(. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION "t[OtE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A :1934-.1968) Permit,, Number Name '� �Lr Date — NO Locaticjy��Ir//,4) X'Ll 9/, t Subdivision Name Lot No. Sec. or Block No. Lot Size Z 7�� House Mobile Home _ Business L'Speculation No. Bedrooms /li;4 No. Baths — No. in Family-��%y'' Garbage Disposal YES .0 NO Specifications for System: Auto Dish Washer YES ❑ NO leoXj�,�j,;%' Auto Wash Machine YES ❑ NO Type Water Supply _— 'This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by *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 day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by��-�- - p Certificate of Com letion Date "The signing of this certificate shall indicate that the system described above has been installed in compliance with the standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for any given period of time. '" `fYf v .� at„ t L Y. . � .: Y a . ' t �,•a ''.. ` o a, t = .r- . �'4r 1445 :DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION ,,�,'tt\Tamt ; �~�.� ^,:.� j ;C, A Subdivision Name: ,ter+ i �- 4 Ifife&1gps-;ojjfoperty. CP'P 'µ" �` /01 Section: Lot: IMPROVEMENT 'a J - r'-1� PERMIT Tax Office PIN:jj# Road Name. * Zip: j1j **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 x, cons tructionlinstallation 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 PERMPf 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 yt�''�3'��' ,#, BEDROOMS # BATHS / # OCCUPANTS GARBAGE DISPOSAL: Yes or No s COMMERCIAL SPECIFICATION: FACILITY TYPE#PEOPLE # PEOPLEISHIFT � # SEATS INDUSTRIAL WASTE: Yes O 19 �/raef LOT SIZE TYPE WATER SUPPLY / i DESIGN WASTEWATER FLOW (GPD)�r NEW. SITE &f REPAIR SITE 01 SYSTEM SPECIFICATIONS:,TANK SIZE ' Jn GAL. PUMP TANK GAL. TRENCH WIDTH ,-r/ ROCK DEPTH LINEAR FT.''%421' ' 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 BY: t AUTHORIZATION NO. / ` 5 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. LA -nu wno kxevtseu) DAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section SECTION LOT Soil/Site Evaluation APPLICANT'S NAME ��/?, �� DATE EVALUATED _ly Z% PROPOSED FACILITY PROPERTY SIZE SUBDIVISION ROAD NAME �D Water Supply: On -Site Well Community Public t__ Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 5 6 7 Landscape position •C Slope % HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH f !c Texture group Consistence - Structure <i Mineralogys 'Z 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: LONG-TERM ACCEPTANCE RATE: REMARKS: LEGEND Landscape Position EVALUATION BY: lI OTHER(S) PRESENT: 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 a 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) ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■eee■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■Nee■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ MENNEN ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■MME■■■■■■■■■■■■■■■■■■�u ■■■■e■■■■■■Nee■■■■■■■■■■■� ■■■■■EE■■■■■■■■■■■■■■■■Nei ■■E■■■■■E■■■ ■■■■■■■■■E■■ ■■■■■■■■■■■■ ■E■■■■■■■N■■ ■■■■■■■■■■■■ ■■■■■■NE■■■■ ■■■■■■■■■■■■ ■■■■■N■■■M■■ ■■■■■EE■■■■■ ■■■■E■■■■■■■ ■■■N■■■■■■■■ ■■■EE■■■■■■■ ■■■■■■■■■■E■ ■■E■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■ ■■■■E■■■■■■■ ■N■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■ ■M■■■■■■■M■■ ■■■ENE■■■■■■ ■■■EMNU■M■■ ■■E■■■ ■■E■ ■■■■■■e■E■E■ ■E■■■■■EEE■■ ■E■■E■■E■E■■ ■■■■■ ■■■■■ ■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■N■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■■■■■■■ ■■■■ ■■■■ NEON NONE NEON NAME ■■N■ N■E■ ■■N■ ME No No ■■ No ME ■■■■■■■■ ■■■■■■■■ ■E■■■EE■ ■EE■■E■■ ■■■E■■■■■■■■ ■N■■■■■■■N■■ ■■■■■■■■■■■■ ■■■■■■■■■■■■ ■■■■■MEN■■■■ ■■N■■N■■■■■■ ■E■■■EE■■■E■ ■EE■N■■■■■■■ ■E■■■■■■EE■■ $� APPLICATION FOR SITE EVALUATION/IMPROVEMENT ,PERMIT & @ j� p -�° S ! Davie County Health Department U U Environmental Health Section P. O. Box 848 Mocksville NC 27028 nn 1�+fl�'YJr?p'1dA V36751-8760 .1V1���� H�litj ****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED INFORMATION IS PROVIDED. 1. Name to be Billed �I/ , l i— j r t� P �Q� Contact Person A 9101Vy1CAV71') V0nC1 7 ' Mailing Address 6 0 7 Home Phone 44 _ J`GI 7.6 City/State/Zip 5-4 fq tZ71 02. Business Phone �6 % A — 2 111 2. Name on Permit/ATC if Different than Above ► -P ep—_© Mailing Address �GI �'I '� City/State/Zip S4 -e 3. Application For: Site Evaluation 2 Improvement Permit & ATC Both 4. System to Serve:, ❑ House ❑ Mobile Home Business ❑ Industry ❑ Other 5. If Residence: # People # Bedrooms # Bathrooms ❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ElBasement/Plumbing ElBasement/No Plumbing 6. If Business/Other: Specify type /� Tll CQS h # People #Sinks # Commodes # Showers # Urinals # Water Coolers If Foodservice: # Seats Estimated Water Usage (gallons per day) 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? ,W Yes ❑ No If yes, what type? _ 1/ aIA l 7/D aW ariy f e,,- &fh ro o -,W - EITHER A PLAT OR SITE PLAN PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A MXMUW THE PROPERTY MUST BE X /� SUBMITTED WITH THIS APPLICATION. Property Dimensions: ���31�� ` " /� /�v� �P1 �� /RITE DDIRECTIONS (from �g So % 0 1 Mocksville) TO PROPERTY: Tax Office PIN: # - �--- 1 j ©� Property Address: Road Name cQ 13 / 60! l A,5 Ch City/zip mc k:5- ✓" 11C &C. If in Subdivision provide information, as follows: ; L Name: 1 1 Section: Lot #: 1 1 1 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 conduct all testing procedures as necessary to determine the site suitability. / DATE `'5 Z — O S Revised DCHD (06-96) YOU MAY USE THE BACK OF THIS FORM FOR DRAWING YOUR SITE PLAN. s :� Pl-- �� U� �: ;� ,. � t� . � ��� � �� r C� �::�� ~ --- .rf � �; ���. 1„'''* � J l �� y w a�cv �\�(9.44 O w J� INDOEV ED z J / QQ' 5729.02 C-) U �Q. v �u 455 I (2.93A) 3533 -1 F M. `� `• (229A) 7404 (a. 0 2422 4378 4 ,T, Al -LEN ROAd 8247 ` SR 1304 215 (4.89A) 5059 INDEXED I 5729.02 (20.G2A) 9326 n 'E 1.525.000 E 1.526.000 E 1.527.000 U Chi (5.85A) 4473 ..'mV 3200 ! 563.54 cD Amlam +fir 0 ;lk 6 W 0 CO 41 I A D D 74 A W £ ti' Z•b Z I ` , O c� NSG% r CD v N W d CV fJ W rn (T) Q 1v I Go ^j N 435.12 - N � m 3i5co G' J 00 O 3-94, -- 3 9.8 9 W tly 770.23 N — 27.03 4.65A, N "� a 640.38 _ w 591. p� !IS N 6 r� 671 . .- ... 0 r O 647 °S n' D jui W -- .)7 1357.50, IN 2- s 700.05 ---__'---- J3o -- �' D �; InLn O 1441.44 n ?y O _ 376 C �? I 92. 2 794 21�Q"-- aW A 10 .. _ `q w o I W W �O fb I N C b U Nrj IC -4 # ti n >50 !ry 2C- 3=• o_'0g 179 D 8003 .:9,596 I A tj-,Oizl 6 W 0 CO 41 I A D D 74 A W £ ti' Z•b Z I ` , O c� NSG% r � ;Y.-'� 4 ti., :: tii Y)iih t''7 .>Srt;zs.;.�_.i.�ev,v"it -.Jas- daB ::7' �• �•tv-.r=4...-•:i ""t.. a"!t_a.:it ;i:i-i +� y„t i' t-' . . "7t'II' f "•'1 ;v:,r Mr'q” � Yir �. , r i . .w t9 y' 4 r i7 j^4 '19 t r�5'i+ : 'AUTHORIZATION NO: 0704 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section PROPERTY INFORMATION Permittee's ,+,� ,1 f P.O: Box 848 Name: �/IJ. !�1 f �/. Mocksville, NC 27028 Subdivision Name; Phone #: 704-634-8760 Directions to property: e� / _ Section: Lot: AUTHORIZATION FOR . WASTEWATER Tax Office PIN:# SYSTEM CONSTRUCTION Road Name: `p, 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 I of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) r ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION IS VALID FOR A PERIOD OF FIVE YEARS._ E F IRONMENTAt HEAL `H 5PE -' ATE ISSUED � t � �'s'".°r i'"^'.,�. xc` -1^rR* �x'o.;nRra='iyt rr e=_',..� G-»;a-ngry v --p7rt5±.+}��c. f sac„G fi" r� P �>'4l� -" t�J'•.' ;•-✓- 'c-;,,¢ r//f+j• '.:. t <ay ..,.:.a•�a/'�„J(� .,� 1 t=+7. DAVIE COUNTY HEALTH DEPARTMENT h ; 'IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION PeriltteE', 1�Ia[e `'�:f.� ,1 .' 1f " Subdivision Name: ti... t Ireetnto property: ions Section: Lot: ' IMPROVEMENT PERMIT Tax Office PIN:# Vol? ***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 z INSTALLING THE SYSTEM. RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No /r? COMMERCIAL SPECIFICATION: FACILITY TYPE e# PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITEy SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH LINEAR FT. OTHER.—�4 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. DCHD 05/96 (Revised) i �' c 8r' �a � ai-.aJ,+.4rr-<� �y....�•� �, '�, t,c f : e � ea+ +-i, y ', ;i•,e F;' . t - :/ '-,i-:...,. �, ..M1:N �.v•..y:�y.;.��•.:fs•.tk.o"t'.;.�.y.,; .-ti �;,,. ... ... � y,:,�i. � a.,; ,.' ,,t � .k �t DAVIE COUNTY HEALTH DEPARTMENTf%L/ w . - IMPROVEMENT AND OPERATION PERMITS .PROPERTY INFORMATION Pernu60-d's , Name:Subdivision Name: 'Directions to property: r° %'` Section: Lot: p• IMPROVEMENT PERMIT Tax Office PIN:#/ r� Road Name: �-`�' 61A1 Zip: 01j 10,Rly, 4*NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or anywastewater 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*** TILS PERMIT IS SUBJECT TO REVOCATION IF SITE ` PIANS 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// j -/r o ; # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE TYPE WATER SUPPLY_ DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE tl SYSTEM SPECIFICATIONS: TANK SIZE GAL. 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) 6348760. OPERATION PERMIT SYSTEM INSTALLED BY: /vrI� i15 , T2s _ 'y AUTHORIZATION NO. 7� OPERATION PERMIT BY: / Y` DATE: **THE ISSUANCE OF THIS OPERATION PERMrr 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 APPLICATION FOR IMPROVEMENT PERMIT (REPAIR) NAME • / Q' el PHONE NUMBER ADDRESS AD 1W SUBDIVISION NAME LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER TYPE FACILITY {NUMBER BEDROOMS /r%�NUMBER PEOPLE SERVED TYPE WATER SUPPLY e o SPECIFY PROBLEM OCCURRING DATE REQUESTED � ��? INFORMATION TAKEN BY This is to certify that the information provided is correct to the best of my knowledge, and that I understand I am responsible for all charges incurred from this application. SIGNATURE OF OWNER OR AUTHORIZED AGENT Parcel #: G30000008003 Davie County, NC - Basic Estate Search Basic Search Real Estate Search Tax Bill Search Sales Search View -Property Record for this Parcel View Mao for this Parcel View Tax Bill Information Parcel #: G30000008003 Account #:78599000 • Owner Information Tax Codes - WHITE LAWRENCE &COMPANY ADVLTAX - COUNTY TA 86 GRANNAMAN DRIVE FIREADVLTAX - FIRE TAX MOCKSVILLE NC 27028 Property Information Township Land (Units/Type): 1.820 AC MOCKSVILLE [Address: 2131 N US HWY 601 Land: Deed Information Local Zoning Date: 04/2015 Book: 00985 Page: 1086 Assessed: Plat Book: 0008 Page: 345 Deferred Legal Description PIN LOT 2 WHITE LAWRENCE S D 5820507404 Property Values Building: 160,8301 BXF: 7201 Land: 141 92 Market: 303 47 Assessed: 303 47 Deferred Sales Information No. Book Page Month Year Instrument Qual/UnQual Improved Price 1 00149 0171 06 1989 WD Unqualified Improved 0 2 00942 0916 11 2013 WD Unqualified Improved 100,000 3 00985 1086 04 2015 WD Unqualified Improved 50,000 View Prooertv Record for this Parcel View Mao for this Parcel View Tax Bill Information « Return to Basic Search Page 1 of 1 oZ-V„ r1 1-OUR'S, Davie County Web Site All information on this site is prepared for the inventory of real property found within Davie County. All data is compiled from recorded deeds, plats, and other public records and data. Users of this data are hereby notified that the aforementioned public information sources should be consulted for verification of the information. All information contained herein was created for the Davie County's internal use. Davie County, Its employees and agents make no warranty as to the correctness or accuracy of the information set forth on this site whether express or Implied, in fact or in law, including without limitation the implied warranties of merchantability and fitness for a particular use. If you have any questions about the data displayed on this website please contact the Davie County Tax Office at (336) 753-6120. 1.5.9 http://maps.daviecountync.gov/itsnet/View.aspx?prid=1116055 8/24/2016