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1'"d A R i Ii "� f•1n- r Y iC
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
elmittee's = Vi,
� l t Subdivision Name:
Directiorns to property: Section: Lot:
PERMIT Tax Office PIN:# _
-.-
Road�i�t t'11.i` f.lZ,p
**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.
Y . (In compliance ith cle of Qh.rehapter 30A, 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
u ENVIRONMENT iHEAtTH tPECIALIST DTE ISSUED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE y
INSTALLING THE SYSTEM. E 4'
RESIDENTIAL SPECIFICATION: BUILDING TYPE iAbi hDBEDROOMS ---L4L # BATHS # OCCUPANTS � GARBAGE DISPOSAL: Yes
_ NO
.COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZES 5 ��/ T WATER SUPPLY �D SIGN WASTEWATER FLOW (GPD) ✓NEW SITE REPAIR SITE '
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH 12 LINEAR FT.
OTHER Dl V:1 J`CIOAXe;S
�Na c�o.� - s Pic t,
REQUIRED SITE MODIFICATIONS/CONDITIONS: 1 Ci
s7A�a. o
F�T 0
IMPROVEMENT PERMIT LAYOUMAPPROVED EFFLUENT FILTER* *RISER(S) IF 691 BELOW FINISHED GRADE*
LNth SOL-If) pill& 10,
�^�.;
. xJ nAt)otto
S-1�
12- ,
MVSY h off, �.I -,f�
POOL
22,
l�
"CONTACT A REPRESENTATIVE OF THE DAVIE CO ALTH DEPARTM INSPECTION OF K137
STEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # I3(RQ4)(WA-
{336)751
OPERATION PERMIT
SYSTEM INSTALLED BY:
t ,
V
AUTHORIZATION NO. S � U IPERATION 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)
'Jt'^'L,it .r�` •k.�t'.i Oi-i `"`y".w�._- '+. ii;'a��",J,�`'`'7 •�'�`KI"Ao"' }� aR '.t�f'' 't^ Y' .^"''11'e„ ..��.�.f _ f- tin-«M'g
.. "�^'Y`.i .. 4 Mt � i _,t.,:. _ d '1' .,' y ,j •,-s^�.d -.' �ar�:w `�W' ���i h d
0 TO t DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
Permittees` j'
Subdivision Name:
Directions to property: ' * � . 1 Section: Lot:
- , 3 IMPROVEMENT
PERMIT Tax Office PIN:# - -
ROadil r�" a a k { �`2ip:
**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 I of P.S.-C. hapter 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
ENVIR&MENTAL;.HEALTH SPECIALIST ; DITEEII§S ED SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION: BUILDING TYPE Il')l E # BEDROOMS Wit_ # BATHS � #OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLEISHIFT ]�# SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE li TY WATER SUPPLY 0 �D SIGN WASTEWATER FLOW (GPD) ✓ NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZEGAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH) � LINEAR FT. w a�
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: ') N r;,,TI\LL.yf� (,,...0��ty �� ' �cx�L �0 S+ o c r
IMPROVEMENT PERMIT LAYOUIX APPROVED EFFLU':HT FILTER* *RISER(S) IF 01 BELOW FINISHED GRADE*
�--. _,...'�' X►STi„ 1�. .;;�' ��� Svt~ 1 � �'1 f i.. 1 U 7'r �:.
IV,
(0..
4.
F
'CU t—
29
1 fm�1
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNVJ
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE
)EPARTM INSPECTION OF THIS SYSTEM
AINSTALLATION. TELEPHONE # I8f(m 0463 t4MG.
(336)751-87611
OPERATION PERMIT
SYSTEM INSTALLED BY:
AUTHORIZATION NO.r,,22fy OPERATION PERMIT BY: �� DATE: J
**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)
t�
Y4
•
��-- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: 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 Fx� Dated 1
Location fir) �� 0/4 /r, /,,% /i�%� -- `.'r x. ::) 413:�r
Subdivision Name Lot No. - Sec. or Block No.
Lot Size i QAIC House Mobile Home _ Business _— Speculation
No. Bedrooms 3— No. Baths —7 - No. in Family 2 -
Garbage
Garbage Disposal YES ❑ NO S ecifications for System: �-
Auto Dish Washer YES i NO ❑ p r , /OpvZ,
Auto Wash Machine YES NO ❑ �`0�` "k / 2 -' ` '' '"
Type Water Supply eloadTy
*This permit Void if
m described below is not installed within 36 months from date of issue.
%ements 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:
1\
System Installed by r'
--------------
r
i1
3
Certificate of Completion Date )– i
S
*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.
NAM
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION �Ko�l� 7o1f-moo _ S9Sa
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
-4p- -k- —IP, , a,, I/ip',
PHONE NUMBER
BDIVISION NAME
LOT #
DIRECTIONS TO SITE �,S S4-4- •> S a �' o�-�-r' b,� p
7&j lC o w-1 ""P f,' %/ t r O N
DATE SYSTEM INSTALLED '9L3 NAME SYSTEM INSTALLED UNDER &r e r CSiWA.,
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED-
-44 sN — 4o 4-e-1 b,4i, r 3 !lz ) M
TYPE WATER SUPPLY C;Dt�1Y SPECIFY PROBLEM OCCURRING W c(,4 i o �' S
from this application.
DATE REQUESTEINFORMATION TAKEN BY I.Q
This is to certify that the Information provided is correct to the beat of my knowledge, t I
SIGNATURE OF OWNER OR AUTHORIZED AGENT 1"
Rev. 1/93
responsible for all charges
C
t
Parcel #: 060000003404
Davie County, NC - Basic Estate Search
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View Property Record for this Parcel View Mao for this Parcel View Tax Bill Information
Parcel #: 060000003404
Account #:75481500
Owner Information
Buildin :
Tax Codes
BXF•
RIESEMA PETER & VRIESEMA GERTRUDE
Land:
ADVLTAX - COUNTY T
1 00112
198 US HIGHWAY 601 SOUTH
ssessed:
FIREADVLTAX - FIRE TAX
Deferred:
MOCKSVILLE NC 27028
18,500
2 00190
PropeM Information
10
Township
Land (Units/Type): 3.260 AC
Vacant
JERUSALEM
[Address: 4198 S US HWY 601
0358
10
Deed Information
Qualified
Local tonin
ate: 10/1996 Book: 00190 Page: 0358
lat Book: age:
Legal Description
PIN
13.256 AC HWY 601 LOTS 3-4
5754222129
Property Values
Buildin :
115,7001
BXF•
19,4401
Land:
Price
1 00112
0456
ssessed:
A4260Market:
Deferred:
Vacant
Sales Information
No. Book
Page
Month
Year Instrument
Qual/UnQual
Improved
Price
1 00112
0456
02
1994 WD
Unqualified
Vacant
18,500
2 00190
0358
10
1996
Unqualified
Vacant
90,000
3 00110
0358
10
1996 WD
Qualified
Improved
90,000
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
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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=1459700 7/29/2016
A�
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;��►UTHORIZATION NO:' ��Q�`� Q� DAVIE COUNTY HEALTH DEPARTMENT
� '' Environmental Health Section .... ,� PROPERTY INFORMATION,
Percnittee ti . '�^ (1 ' P.O. Box "848 '
Name: ��..�1�.`���.' �!�- �..(��� � �'`� Mocksville, NC27028 Subdivision Name:
` � ' ' � ` Phone #;336-751-8760. `
Directions to�property '�� 4' Section: Lot:
�,��r r�} �AUTHORIZATTON FOR',
`. '`���''T ' , `r�h.. � " i ia� 1L-�+*.) ' WASTEWATER ',Tax Ofiice PIN:# -
SYSTEM CONSTRUCTION �
' Road���v�'l�t�U'7 �ip:'^G�- l�-�`
I**NOTE**.`This Autfiorization'for Wastewater System Consuuction MUST,BE 1SSUED by the Davie County Envuonmental�Health Section prior -
-.
' 't� issuance of anyBu'ldingPernuts;"This'Form/Authorizafion Number should bepresented ro the. Davie County. Building Inspections �
Office when apply` g for$uilding Permits ` �� ,. ;: �
:� (ln compli� e� itM, ' 1e 1 of �r�fiapter 30A; Wastewater Systems Section :1900 Sewage Treatment and Disposal Systems) :
;"~- ***NUTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCI'ION
T w! Z (� IS YALID FOR A PERIOD OF FIVE.YEARS.
. , ,,
., -
,, . � .;� ,: . �.. , . �
..
ENVI ON TH P-�C LIST' D E ISSUED
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