2497 Hwy 601S�� � . n.-, i'. i;iv. 4 5"•i.F T '�f .l . . S t �,rw �, ! 1 Y _ .s, ... . i . . . ,/0.
DAVIE COUNTY HEALTH DEPARTMENT
. L•r t .. iT.. '...�4
IMPROVEMENTS PERMIT AND . CERTIFICATE OF COMPLETION
*NOTEAssued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems ,�� _ Permit Number
Name /7/r� �, t1 �,' ��l , r c� 3 1't' Date —�� �� ` ��'� NO -14-
66
l .
G 6 1�.
LocatCn-
Subdivision
Name Lot No. Sec. or Block No.
Lot Size House Mobile Home — t;!:� Business Speculation
No. Bedrooms No. Baths — No. in Family _ �_—
Garbage Disposal YES ❑ NO []" Specifications for System:
Auto Dish Washer YES Q NO ❑ {��}�I—) / / I
Auto Wash Ma shine YES M NO ❑ iI/�/
Type Water Supply _—� �,�'� , •
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
Improvements permit by —r :
*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
I �7b
�--- -a-�
Certificate of Completion L� Y 1'\ 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.
F-'
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Re uested y �. !G
Mailing Address o
Home Phone
2. Name on Permit if Different than Above
3. Application/Permit for:
4. System to Serve: ❑ House
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
❑ General Evaluation
!'M�obile Home
❑ Other
No. of Bathrooms _,/
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Sinks _
No. of Urinals
Septic Tank Installation
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
Washing Machine
Dishwasher
❑ Garbage Disposal
No. of Lavatories No. of Water Coolers
No. of Showers � Water Usage Figures
7. Type of water supply: 2 Public ❑ Private
8. Property Dimensions ,/w Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes
If yes, what type?
■
❑ Community
*NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
,,,, V) - 1;7 -
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred fromVasoation%
c4
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
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
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE
DCHD (12.90)
SIGNATURE
0
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME
ADDRESS
PROPOSED FACIILTY 'ge ,ALa e
Water Supply: On -Site Well
Evaluation By: Auger Boringy
DATE EVALUATED _
=2 '�
PROPERTY SIZE
/ rw e
LOCATION OF SITE
e DlS
Community Public
Pit Cut
FACTORS 1
2
3
4
Landscape position L.
L
A-
.L-
Slo e %
2
HORIZON I DEPTH
°e
Texture group
<,,I—
Consistence '
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
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: 4'%J .
LONG-TERM ACCEPTANCE RATE: L�
REMARKS:
DCHD(01-901
EVALUATED BY:L
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 -Finn 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
Mineralog
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
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■EMKO■
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Parcel #: L514OA000601
Davie County, NC - Basic Estate Search
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View Property Record for this Parcel View Man for this Parcel View Tax Bili Information
t
Parcel #: L5140A000601
Account #:21114000
Owner Information
Tax Codes
ILLARD CLARENCE CLAYTON& C/O PENNY D SEAFORD
ADVLTAX - COUNTY TAX
193 BYERLYS CHAPEL ROAD
READVLTAX - FIRE TAX
MOCKSVILLE NC 27028
15,31
arket:
Property Information
Township
Land (Units/Type): 0.950 AC
JERUSALEM
ddress: 2497 S US HWY 601
09 1987 WD
Deed Information
Local Zoning
Date: 04/2008 Book: 00755 Page: 0225
3
Plat Book: 0003 Page: 015
08 1991 WD
Legal Description
PIN
LOTS 9-14 HWY 601 LIFE ESTATE
5746424193
Property Values
Book Page
Buildin
Qual/UnQual
BXF•
4,81
nd•
15,31
arket:
20,1200001111
ssessed:
20 12
eferred•
00140 0109
Sales Information
No.
Book Page
Month Year Instrument
Qual/UnQual
Improved
Price
1
00755 0225
04 2008 WD
Unqualified
Improved
0
2
00140 0109
09 1987 WD
Qualified
Vacant
5,000
3
00160 0613
08 1991 WD
Qualified
Vacant
6,500
View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information
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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
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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=765032 7/19/2016