4395 Hwy 64W (2)�''- ,.r Yr:� � _. "i '� w:y; .;: �_' .s•. a -b '.3-°�... 'ss'L mom• '''+' ?. . .=•;. „',. _ ...,, -
>' EAT;TH DEPARTME
Permittee's r ' ,'` DAVIE COUNTY HNT
I,
Name: Environmental Health Section PROPERTY INFORMATION
Directions o property: �" 0/15`vi 1 NC 27028 Subdivision Name:
!���rG �'` , ..- Phone #: 336-751-8760
} -s r .�!� i�%. Section: Lot:
AUTHORIZATION FOR
y WASTEWATER
e.% Tax Office PI
N:# - -
��•� { 'SYSTEM CONSTRUCTION
,,XLFMORIZATION NO: 2079 A Road Name: 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 compl iance,with Article 1 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.
1 NVIRONME1fTAL HEALTH S CIALIS DATE ISSUED
RESIDENTIAL SPECIFICATION: BUILDING TYPE # BEDROOMS # BATHS # OCCUPANTS GARBAGE 151SPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE�OPLE # PEOPLE/SHIFT # SEATS
"7(/ INDUSTRIAL WASTE: Yes or No
LOT SIZE TYPE WATER SUPPLY ✓�� DESIGN WASTEWATER FLOW (GPD) P NEW SITE - REPAIR "SITE b�
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTHROCK DEPTH LINEAR FT.
OTHER 7,w,4 a P
REQUIRED SITE MODIFICATIONS/CONDITIONS:
7�
IMPROVEMENT PERMIT LAYOUT , i o paJ dw
/ I wiv
/17
**CONTACT A REPRESENTATIVE OF THE DAVIECO Y HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M N THE DAY OF INSTALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
SYS INSTALLED BY:
�1
AUTHORIZATION NO. q-0 — 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.
DCHD 02102 (Revised)
�IC ct I ep &/x /
DAVIE COUNTY HEALTH DEPARTMENT .
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name "�%''`: �'' "�r;� _ Date��.� %; No 8�; -1
Location
Subdivision Name Lot No. Sec. or Block No.
Lot SizeT' •__—__ House — Mobile Home _--- Business —��� Industry
No. Bedrooms 1.ZILL No. Baths No. in Family - — Public Assembly Other
Garbage Disposal YES p NO p--. Specifications for Syste
Auto Dish Washer YES p NO lei y- I i
Auto Wash Ma^hine YES p NO [-]---�
Type Water Supply — — �r�' — ---- --- 4-'
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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM. \
75
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Insta
9 «,a.
`To --k
Certificate of Completion! �_ --Date - V► _
The signing of this certificate shall indicate that the system described above has been installed in compliance with
the standards spt forth in the ahnva roni ltatinn i—t choll ;n Ale) ..mv tin 0-.1..... .-.. - - .--. - • ••
C kel(_
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
r) C PHONE NUMBER
P/'V Ply
DDRESS V3 1 S' L V SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY 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 applioation.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1/93
M
DAVIE COUNTY HEALTH DEPARTMENT FIIN_XQ
4 IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems PermitNumber
Name ,"� % ✓� lir/ D e N12 8167
A
i r
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size —," . G — House — Mobile Home _--_ Business —L Industry
No. Bedrooms 1�1L .No. Baths _�4_ No. in Family `� _ Public Assembly Other
Garbage Disposal YES ❑ NO 2--� Specifications for Syste nn
Auto Dish Washer YES ❑ NO
Auto Wash Ma^hine YES ❑ NO R ----
Type Water Supply -- ----- --- X_? /41
'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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM. \
Improvements permit by
Oe
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634.5985.
Final Insta
X=w
G)
Tek
Certificate of Completion �! �_�l�n�.� --Date 1 a�
'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.
ct IIe4P40i
».. , DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: Issued in Compliance With Article ll of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name X DVe >? '1 Jr N2 8167
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size /. I House — Mobile Home —_._ Business _� Industry
No. Bedrooms x'11_61 No. Baths —— No. in Family_— Public Assembly Other
Garbage Disposal YES ❑ NO [' Specifications for System:
/ Auto Dish Washer YES ❑ NO L
Auto Wash Ma^hine YES ❑ NO
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
-ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
u
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Insta
0A `_.
\ S� 1 - 1 BIZ
A- d Z - 1 1) Z_
Certificate of Completion, \_ 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
". Davie County Health Department
j'- Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By +a'�/�u 2. ST20 Q
Mailing Address y3 216(i S/ 6o it 6J EST Home Phone '7� i�) �%- 'S$ Z
Pn 0 CSS Vi//F /V,(', 2 -70 E Business PhoneL7 o j) SG92 -5-10/
2. Name on Permit if Different than Above �
3. Application for: El General Evaluation 2 Septic Tank Installation Permit
4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly
M Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served dit,,, a O�'x-�/A SCT-
No. of Commodes a
No. of Lavatories oZ 45;5 66 3
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
No. of Sinks l" d2.gA_ C- S AIk . / AZIAo
No. of Urinals /5 /
No. of Water Coolers I'
No. of Showers Water Usage Figures 7
7. Type of water supply: C/ Public ❑ Private ❑ Community
8. Property Dimensions Nlu ZZK3 '� Sewage Disposal Contractor /
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes M No
If yes, what type?
'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:
gP�,Poy /0 M/,cF-s wf 6 fa Gl I v.v/�" o ry ffiy�w.�j 6
�'X 'o✓ G.9so 4,✓F = .T -,C. sr7"vo'S G L c-ny 0
FjL 9 S)w - x;., r fro •v o� �OGF-.�ti sra >Q' �d��l w•�j �/�
IVCvnCJXrf �51V,,i-�' J , /6 Z o �NiS ✓`E' 0
A✓� , q 7a Cvs fa> -00 P �� 110i1 j 1` 9 45 o
/P .�-o�, we ivr�lr, 6c
At- ,ec st A" wslrczs ,... - /tet A," ,ate 4vm sd s
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 from this application.
/JP 1051y6: 9)'- A -
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. L12. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner ora 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 d6 --.LS/ L �, ,S T2yab
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
/X 19ya 9-C
DATE SIGNATURE
DCHD (1193)
Parcel #: J10000001902 Page 1 of 1
qP�t�
Davie County, NC - Basic Estate Search wri-I
Davie County Web Site
.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 #: 310000001902
Account #:71556000
Owner Information
Bulldin :
Tax Codes
BXF:
ROUD BILLY R& STROUD BEVERLY 3
[361
Land:
ADVLTAX - COUNTY T
Market:
US HIGHWAY 64 WEST
ssessed:
FIREADVLTAX - FIRE TAXCKSVILLE
Deferred
NC 27028
Property Information
Township
[Land (Units/Type): 1.340 AC
CALAHALN
ddress: 4395 W US HWY 64
Deed Information
Local tonin
Date: 07/1996 Book: 00188 Page: 0444
Plat Book: Page:
Le al Description
PIN
1.722 AC OFF US HWY 64
4798509523
Property Values
Bulldin :
36 22
BXF:
2,4301
Land:
66 93
Market:
105 58
ssessed:
105 58
Deferred
Sales Information
No. Book Pape Month Year Instrument Quai/UnQual Improved Price
1 00188 0444 07 1996 WD Unqualified Improved 48,000
View Property Record for this Parcel View Map for this Parcel View Tax Bill Information
« Return to Basic Search
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/itsneWiew.aspx?prid=1466680 7/12/2016