3442 Hwy 601N'AUTHORIZATION NO: �: Q 1E COUNTY HEALTH DEPARTMENT
w , Environrimental HeAth'Section PROPERTY INFORMATION
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.=;Permittee's P.O. Box 848 '
Naive-[ Y1t%!�'t l',� • Mocksville; NC 27028 Subdivision Name:
Phone # 336-751-8760
Di-ections to property:' Section: Lot:
AUTHORIZATION FOR.
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION
Road Name: Zip;
.**NOTE** This Authorization for Wastewater System Construction MUST BEISSUED by'the Davie County Environmental Health Section prior,
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to issuance, of any Building -Permits. This Forrn/Authonzation Number should be presented to the Davie County Building Inspections
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Office when applying for.Building Petm�ts.
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(In compliance with Article I 1 of G.S..Chapter_130A,.Wastewater Systems, Section Sewage Treatment and Disposal Systems)
.1900
***NOTICE***, THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
-
- IS VALID FORA PERIOD OF FIVE YEARS.
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED
04 DAVIE COUNTY HEALTH DEPARTMENT
- �`• �`. IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
�F,�-P&iruttee's
Subdivision Name: t✓�
DI'ections to property: Section: Lot:
�5 EAPROVEMENT
PERMIT Tax Office PIN:# %` - -
Road Name: Zip:
**NOT$**, This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An l�
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION must be obtained from this Department prior to the
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construction/installation of a system or the issuance of a building permit. uc
(In compliance with Article I I of G.S. Chapter:I30A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
r' *.**NOTICE*** TIUS PERMIT IS SUBJECT TO REVOCATION IF SITE
f, e r 7 r �!% ' ', ''; PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER
ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFO
INSTALLING THE SYSTEM. .
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION.
FACILITY TYPI/# PEOPLE # PEOPLE/SHIFT_ # SEATS INDUSTRIAL WASTE: Yes
LOT SIZE TYPE WATER SUPPLY .DESIGN WASTEWATER FLOW (GPD) NEW SITfi REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZV4&d—GAL. PUMP TANK GAL. TRENCH WIDTH ?Z ROCK DEPTH (LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
05/96 (Revised)
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APPLICATION FOR SITE EVALUATION/IMPROVEMENT PERMIT & ATC
Davie County Health Department
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)751-8760
***IMPORTANT*** THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed e d S • II,S 1 Gt, 1 K c �'• '
Mailing Address .3 ,p�
city/state/zIP /'i7 O C K-5 V t I I e- t. c. 27 o a%
2. Name on Permit/ATC if Different than Above
Mailing Address
Contact Person
Home Phone 11-9-1 - .S .z 9 O
Business Phone
City/State/Zip
3. Application For: ❑ Site Evaluation ❑ Improvement Permit/ATC ❑ Both
4. System to Service: ❑ House ❑ Mobile Home Pr Business ❑ Industry ❑ Other
5. If Residence: # People # Bedrooms # Bathrooms
❑ Dishwasher ❑ Garbage Disposal ❑ Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Industry/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 ❑ Well ❑ Community
8. Do you anticipate additions or expansions of the facility this system is intended to serve? ❑ Yes A'No
If yes, what type?
***IMPORTANT*** CLIENTS MUST COMPLETETHE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a PLAT or SITE PLAN MUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions:
Tax Office PIN: #
Property Address: Road Name
City/Zip
If in a Subdivision provide information, as follows:
Name:
Section: Block: Lot:
WRITE DIRECTIONS (from Mocksville) to PROPERTY:
4,01 N 3 o -f Lim R lb. ci -�
U N .Coil'
Date Property Flagged:
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 if � r =t Ru.Th WFI1-wee -
to conduct all testing procedures as necessary to determine the site suitability.
DATE SIGNATURE
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN (Include all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic locations).
Revised DCHD (07/99)
Site Revisit Charge
Date(s):
Client Notification Date:
EHS:
Account No.
Invoice No.
Davie County, NC
Tax Parcel Report
Wednesday, August 24, 2016
T*�33
Parcel Number:
E300000067
NCPIN Number:
5821054767
Account Number:
82522953
Listed Owner 1:
WALKER RUTH P
Mailing Address 1:
3442 US HIGHWAY 601 NORTH
City:
MOCKSVILLE
State:
NC
Zip Code:
27028-0000
Zoning Overlay:
19 AC HWY 601 LIFE
Legal Description:
ESTATE (1 6.740AC)
Assessed Acreage:
16.74
Deed Date:
2/2012
Deed Book/Page:
008820538
Plat Book:
11
Plat Page:
223
Building Value:
118480.00
Outbuilding & Extra
5240.00
Freatures Value:
Land Value:
147710.00
Total Market Value:
271430.00
Total Assessed Value:
176740.00
WARNING: THIS IS NOT A SURVEY
Parcel Information
Township:
Clarksville
Municipality:
Census Tract:
37059-801
Voting Precinct:
CLARKSVILLE
Planning Jurisdiction:
Davie County
Zoning Class:
DAVIE COUNTY R-20
Zoning Overlay:
Voluntary Ag. District:
No
Fire Response District:
WILLIAM R. DAVIE
Elementary School Zone:
WILLIAM R DAVIE
Middle School Zone:
NORTH DAVIE
Soil Types:
MnC2,MnB2,MdD,WATER
Flood Zone:
x
Watershed Overlay:
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