2657 Hwy 801NPhone: (336) - 753 - 6780
Davie County Health Department
C E 1 V vironmental Health Section
P.O. Box 848
UL 15 2011 210 Hospital Street'
Courier #: 09-40-06
Mocksville. NC 27028
ON-SITE WASTEWATg1t�C-ERICATION
(Check One) Replacement K Remodeling Reconnection
Fax: (336) - 753-1680
Name: Phone Number 33(DQg q g l q 8 (Home)
Mailing Address: K) & / 7 7, Ll (Work)
nn o�, :,; e tQC a '?C>a g
Detailed Directions To Site: 1 ''
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: h C CbveTypeOf Facility:
Date System Installed (Month/Date/Year): ? 1 1p Number Of Bedrooms:__Number Of People:
Is The Facility Currently Vacant? Yes (2N If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: P(,)61 Number Of Bedrooms: fj "N Number of People AJ A
Pool Size: d O X 40 Garage Size: 4 J A--- ` Other: 1V I*::l
Requested By: 1 Date Requested:
(Signature)
For Environmental Health Office Use Only
Approved Disapproved
Environmental Health Specialist` Date: —71 ?- I
*The signing of this form by the Environmental Health Staff Min 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.
Payment: Cash Check Money Order # Amount:$ ZVU.QU Date: -/— /K—//
Paid By: & rVlcl UA%'G Received By:
Account #: 671- -S Invoice #: ' 7�d�
•- ,. ,.. ,.. �,,. 's. -q.:. ... ,.: i.: ,�-h . , yr -r '4^ae...- wC .. �'. F, - .Y 'f7 sl S:.. r. r ... 4.: ;�� t r r - ..`. '. //
DAVIE COUNTY HEALTH DEPARTMENT
'x IMPROVEMENT PERMIT and OPERATION PERMIT
tri.
(IMPROVEMENT PERMIT
**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 11 of G.S. Chapter 138A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME /7ie/D1/11 if& 4 1& PROPERTY ADDRESS � UEM / DATE �C1i!s-/9r
IL
LOCATION AY— (/�C_�OrS� � r.� A� /ivr DD �r'f le—
SUBU1Vi51UN NHMt LUI NURUtK btL./15LULK NUMMK
RESIDENTAL SPECIFICATION: BUILDING TYPE RC1 # BEDROOMS # BATHS # OCCUPANTS -Y GARBAGE DISPOSAL: Yes Nb
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE jtf!f REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE /DIY GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH ,1 LINEAR FT. 1pd
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS: " >�U�� A191' A, !/,Gr1W
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE DANS OR THE INTENDED USE CHAFE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
r -
IMPROVEMENT 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:WI :30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SYSTEM INSTALLED BY csr�r
• I �-� -d Ds� I
661
AUTHORIZATION NO. ` RATI Aj '1 1� DATE 6 4 4
**THE ISSUANCE OF THIS OPERATION PERMIT SHAL IN T T THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WITH
ARTICLE 11 OF G.S. CHAPTER 130A, SECTION .1900 " 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 10/95
a',y •:.N,� �1 .4 wi'�a yy� t; �� a +rG '" �7y(e .'� fs y>: y .r`t ^.,�"a. �rfr F . 5..... '� " _ `t+. ,:` j` Y t. r * .
Davie:County Health Department
ENV I �_
RONMENTAL.HEALTH SECTION
s „s P.O. Box 665
Mocksville, N.C. 27028
;F AUTHORIZATION FOR WASTEWATER SYSTEM tONSTRUCTIO!
in compliance with Article 11 of
6:5 Chapter 130A, Wastewater Systems)
***This Authorization For Wastewater System Construction must'be•issued.,by the Davie County ,Envi`romental Health Section prior to
issuance of any Building Permits. This Fore/Authorization Number should be presented to the Davie County Buildiq Inspections .
Office when applying for Building Permits.***. �K
AUTHORIZATION NUMBER
NAME ,T DATE S = 95 N 0.i 9r
WE
ON IMPROVEMENT PERMIT (If different than above)
SITE LOCATIO! ` r
COMMENTS/CONDITIONS ON AUTHORIZATION`'TO CO15TRl1CT WASTEWATER SYSTEM
'
**MICE*** THIS AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION IS VALID FW A PERIOD OF FIVE (5) YEARS.
ENYIRONNEAITAL HEALTH WgIALIST, DATE
DCHD 10/95
:APPLICATION FOR SITE EVA UATIO PROV
Davie County Health Department
Environmental Hedlth Section/B
P. O. o� 665
Mocksville, ; 27028
1. Application/Permit Requested By _
Mailing Address O
2. Name on Permit if Different than Above
3. Application for: �/;
4. System to Serve: us`e
❑ Business ❑ Industry
5. If house, mobile home: Subdivision
No. of People /
5M
013 [E 0
NOV 14
t T1-/-' r Home Phone / / U/ 7(� -C7-//
/C -
70669 Business Phone 7b zZ/�79 7` 6 42(-)
)/al Evalu tion i' q•8eptic Tank Installation Permit
❑ Mobile Home ❑ Place of Public Assembly
❑ Other
No. of Bedrooms
No. of Bathrooms J f
Dwelling Dimensions
(0 Zl9
6. If business, industry, place of public assem y, other. Specify type
No. of People Served
No. of Sinks
❑ Unknown
Section Lot #
M-19-a'sement/Plumbing
❑ Basement/No Plumbing
EP Washing Machine
ishwasher a>`
❑ Garbage Disposal
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Publicrivate ❑ Community
8. Property Dimensions 5 GLS% Sewage Disposal Contractor
9.'Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes &Nd--
If yes, what type?
t
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvement3 Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
PROPERTY INFORMATION
Directions to Property: Tax Of f ic�i
Road Name 1
c>& --7s • ��� -9- a-��� p t� Box # (if avail/able)
�no City 111 1Ylj) I
'�vrUle -I-o E C'-ro s5 kc;c c.
h�
e- 0 OLA a5 fi
LJ -V -)a- ire, w t kbe
o � �t� c�-1-, }� lQrhSe � a t � w ►z -c_ ►-L � a �
Cpm o u 4- . -Tk o -4e s 4o
Vri►/e(.VaiS 1 r nacfisv� 0.. p sf2c'--e 'S W W
his is to certify that the information provided is correct to the best f my kno
incurred from this application.
A!)
DATE
amp
edge, and I understand 1 am responsible for all
SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DEESaCaRlB
PROPERTY
UVJ
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 _A -I-Q ) 1-ky�AM*1
to conduct all testing procedures as necessary to determin said site's suitability f ground absorption sewage treatment
and disposal system.
11-1�3' J ull
DATE 91GNATURE
DCHD (193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME /" 01 FZ 4/
ADDRESS
PROPOSED FACIILTY !` '
DATE EVALUATED ey/y/oS
PROPERTY SIZE /S ",7 e
LOCATION OF SITE �D%%Ay,•r.
Water Supply:
On -Site Well �/ _
Community
Public
Evaluation By:
Auger Boring
Pit
Cut
FACTORS 1 1
2 3 4
Landscape position
F
I
Sloe %
_V
HORIZON I DEPTH
e- 5pe o
Texture group
Consistence
Structure
MineralogX
HORIZON II DEPTH
Texture groupG
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 71 T7
LONG-TERM ACCEPTANCE RATE
,
SITE CLASSIFICATION: /�J ✓ �'® �L` EVALUATED BY:�
LONG-TERM ACCEPTANCE R TE: OTHER(S) PRESENT:
REMARKS: �fl1CfL - /!l : i`� ! y✓ C�
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 .;lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V1�--y friable FR -Friable FI -Firm 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
3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralogy
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
DCHD(01-901
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Parcel #: C50000002803
Davie County, NC - Basic Estate Search
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Parcel #: C50000002803
Account #:49134590
Owner Information
uildin :
Tax Codes
BXF•
CCUNE DAVID WAYNE& MCCUNE MELODY S
nd:
ADVLTAX - COUNTY TA
arket:
657 NC HIGHWAY 801 NORTH
ssessed•
READVLTAX - FIRE TAX
eferred:
MOCKSVILLE NC 27028
Property Information
Township
nd (Units/Type): 2.520 AC
FARMINGTON
I.A 2657 N NC HWY 801
Deed Information
Local Zoning
Pate: 03/1996 Book: 00186 Page: 0112
Plat Book: Page:
Legal Description
PIN
91 AC HWY 801
5842274738
Property Values
uildin :
197,86
BXF•
20,38
nd:
41,23
arket:
259,47
ssessed•
259,47
eferred:
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
1 00186 0112 03 1996 WD Unqualified Vacant 0
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=1472688 9/22/2016