3322 Hwy 601S` V
d• `
Pis t�
;
Phone: (336) - 753 - 6786
Davie County Health Department
Environmental Health Section
P.O. Box 848
210 Hospital Street
Courier #: 0940-06
Mocksville, NC , 27028 '«
Fax: (336) - 751-8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING
(Check One) Replacement Remodeling Reconnection
Name: //� w /'Yl •�i¢y Phone Number 6 (Home)
Mailing Address: 33,;0,2 AIA&y/w" (Work)
/L0, /vim 27c; ze- Email me to /7 4- 7 !P y"?C c • N�"�
Detailed Directions To Site: / e R /yl /LES & Ed!�T /,y 7,K1z6t c r1,& ,✓ Or 4S efd j
T—o a
Q us 60/ gAJ
Property Address: 3 3 Q(5? U S U 1 S -06
Please Fill In The Following Information.About The EXISTING Facility:
Name System Installed Under PW v1,D 14 1�r,?E?gX Type Of Facility: I-IDZM
Date System Installed (Month/Date/Year): �/� Number Of Bedrooms: Number Of People: 3
Is The Facility Currently Vacant? Yes If Yes, For How Long?
Any -Known Problems? Yes 6P If Yes, Explain:
Please Fill In The FolloNying Information
�About The NEW Facility:
Type Of Facility:oZ/ X 30 Number Of Bedrooms: Number of People
Requested By: G Date Requested: /_'2 /,P -Z z-,?
ignature)
For Environmental Health Office Use Only
pproveAD Disapproved `
Comments: %y!Q Qq_� �� O +P o �cf/
Environmental Health Specialist Date: /-�A —
*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.
Money Order #,
Paid By: --- L
Account #:
Amount:$
Received By:
Date:
All data Is provided as 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 �G U t34
Davie, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to or arising out of P ri nted: Dec 03, 2013
the use or inability to use the GIS data provided by this website.
-" DAVIE COUNTY HEALTH DEPARTMENT
Ili,
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
t S/ wage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �)%'t1T;' ,.�° �r� % ter' << Date
Location `
Subdivision Name
Lot No.
Sec. or Block No.
V
Lot Size House --r Mobile Home _ Business Speculation _
No. Bedrooms T' _ No. Baths No. in Family_
Garbage Disposal YES .0 NO g3— Specifications for System: i
Auto Dish Washer YES NO
Auto Wash Machine YES LJ NO p
Type Water Supply
"This permit Void if sewage system described belo is nbt insta\ed within 36 months from date of issue.
Cid
1v�f
/a
Improvemei
'Contact a representative of the Davie County Health Department for final
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone N mber: 71
A
Final Installation Diagram�` Syste Installed
7
S �
J
it b
Y
�of this system between 8:30-
85.
Certificate of Completion j /lJ f / 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.
RECEIVED MAR 1 7 1906
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
L 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.
Home Phone 6 3 - 3 -_2 -)-,C
1. Permit Requested By /77 4-G2,�7T Business Phone r y- JL5 G /
2. Address 2 r z-1 ! X r —/ E w. c°'_ 2 Jot
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional 'Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House ✓ Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions r- X 3/74 2
Bed Rooms 3 Bath Rooms Z 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 urinal
lavatory
dishwasher
showers
sinks 3
garbage disposal
washing machine 1
8. a) Type water supply: Public, Private Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions X 3 5 9_ 6 7
:2K -cb) Land area designated to building site /SO ":2K -
c)
) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 1st
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
St -:e 6V � 13.gP i%S Y 1yc�,�c L o •r i S i9�.Pe o X0-4
i
DCHD (6-82)
` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
'. P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name /
Address
ell
FACTORS
AREA 1 AREA 2
Date
Lot Size
AREA 3 AREA A
1) Topography/ Landscape Position
U
S
S
S
PS
U
S
PS
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PS
S
PS
U
S
PS
U
f) Soil Structure (12-36 in.)
Clayey Soils
U
U
S
PS
U
S
PS
U
1) Soil Depth (inches)
PS
—(t�
U
S
PS
U
S
PS
U
) Soil Drainage: InternalS
S
> IPS
U
U
S
PS
U
External
S
PS
U
S
PS
U
1) Restrictive Horizons
Available Space
pg
U
PS
U
S
PS
U
S
PS
U
) Other (Specify)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
1) Site Classification
r�
U—UNSUITABLE
Recommendations/Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE A PS—Provisionally Suitable
Title
Date �—
1
Parcel #: N600000088
Davie County, NC - Basic Estate Search
Basic Search Real Estate Search Tax Bill Search Sales Search
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
Parcel #: N600000088
Account #: 48834900
Owner Information
Tax Codes
CCRAY DAVID WAYNE& MCCRAY BETTY T
ADVLTAX -COUNTY T
322 US HIGHWAY 601 SOUTH
VIREADVLTAX - FIRE TAX
OCKSVILLE NC 27028
ssessed:
Property Information
Township
Land (Units/Type): 1.350 AC
JERUSALEM
ddress: 3322 S US HWY 601
Deed Information
Local Zonin
Pate: 12/1985 Book: 00129 Page: 0412
Plat Book: 0005 Page: 140
Legal Description
PIN
OT 1 BOXWOOD ACRES
5755038442
Property Values
Building:
114,4101
BXF:
24 78
Land:
20 87
Market:
160 06
ssessed:
160 06
Deferred:
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
1 00129 0412 12 1985 WD Unqualified Improved 0
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
« Return to Basic Search
Page 1 of 1
v .w1F
00 tz�
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=1459697 8/3/2016