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Pe -it es's h� i DAVI �COVNTY HEALTH DEPARTMENT
;.Name ir�,C�►�) I l�t�' 1V1Ar� 16VIronmental Health Section PROPERTY INFORMATION
(.)�ta i rVtl . P.O. Box 848
Directions to property: Mocksville, NC 27028 Subdivision Name:
o v4 Phone #: 336-751-8760
Section: Lot:
AUTHORIZATION FOR
WASTEWATER Tax Office PIN:#
SYSTEM CONSTRUCTION - -
AUTHORIZATION NO: Z 027A Road Name:
**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 compliance with Article I I of G.S. Chapter 130A,:Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
$' ***NOTICE*** THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION
•' IS VALID FOR A PERIOD OF FIVE YEARS.
�I VIKSN 1`s AIy EALTH S1PEQrALIST DAT
RESIDENTIAL SPECIFICATION: BUILDING TYPE ,#,BEDROOMS # BATHS # OCCUPANTS GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes or No
LOT SIZE 12 -1 �''�'PE WATER SUPPLY C'� `DESIGN WASTEWATER FLOW (GPD) w CO NEW SITE REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE GAL. PUMP TANK GAL. TRENCH WIDTH ROCK DEPTH (ZI LINEAR FF.�
OTHER 5 /7)l Sxk- i 11x) 0^1 Ltd X &S f <Gr- L ISji TQ'Jy- .
REQUIRED SITE MODIFICATIONS/CONDITIONS:
JJ STAU_ U+J GU,y, inJti
IMPROVEMENT PERMIT LAYOUT
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**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTIO 14 OF THIS SYSTEM �X1 X11
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (36)751-8760.
10 C
OPERATION PERMIT w\�
SYSTEM INSTALLED BY:
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AUTHORIZATION NO. OPERATION PERMIT BY ATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT H STEM 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 07!02 (Revised)
a
DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
nn APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
NAME 1- `� J`�► n t'�`� ( � PHONE NUMBER q'W y'�IL
ADDRESS 'Jao ''��� ��'`� SUBDIVISION NAME
LOT #
DIRECTIONS TO SITE
DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER`�`�
TYPE FACILITY aC+� NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY �" *rf SPECIFY PROBLEM OCCURRING _�400,36 ao
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 application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT
Rev. 1193
J .$ -� ' k _ ^M"^ -4:.-.'._ Y: �4 .++a;y :me... . Jiw=i W J�-k-'• .,.,..r! .a y:, u r. . f- s +
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DAVIE COUNTY HEALTH - DEPAATMENT
IMPROVEMENTS PERMIT AND CERTIFICATE., OF COMPLETION
*NOTE: Issued in Compliance with G.S,. of North Carolina Chapter 130 Article 13c
Sewage"•Treatment and Dis al Rules (10 NCAC 10A :1934-.1968) Permit. Number
. Name /% �''�%; ,r C ; z Date ' 5779
Location
Subdivision Name Lot No. Sec. or- Block No.
Lot Size "5zm House Mobile Home Business v�J Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO C] Specifications for System:
Auto. Dish Washer YES ❑ NO
Auto Wash Machine YES p NO p /'GGG cf f
Type Water Supply�-
*This permit Void if sewage, system described below is not installed within o th from date of issue.
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I
r�; Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between ,8:30-
9:30 AM., or. 1:00-1:30; P.M. on day of completion, Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by4 9 2
fL
l ,
Jam` Certificate of Completion r�' Date
*Ta signing of this certificate shall indicate that the system describ, d above has been installed in compliance with
th standards set forth in the above regulation, but shall in NO-waybe'taken as a guarantee that the system will function
satisfacto'rly for any given period of time.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
e12 R 0. Box 665 rll Nbv
Mocksville; N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL I PROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Macedonia Moravian Church Business Phone 998-4394
2. Address Route 4 (Hwy 801) Advance, 'NC 27006
._3. Property Owner if Different than Above
Address
4. Permit To: a) Install X 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
Industry Other Church
b) Number of people 150
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms 4 Den w/Closet
b) If Business, Industry or Other, State: Number of persons served 150
What type business, etc. Church
Estimate amount of waste daily (24 hours) varies
7. Number and type of water -using fixtures:
commodes 10 urinals .,l garbage disposal --
lavatory 6 showers -- washing machine --
dishwasher -- sinks 1
8. a) Type water supply: Public X Private —,Community -
b) Has the water supply system been approved? Yes x No
9. a) Property Dimensions four (4) acres
b) Land area designated to building site 8.000
c) Sewage Disposal Contractor H. B. Salmons, Yadkinville, NC
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? no
What type?
This is to certify that the information is correct to the best of my knpwledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL ,LAWS
Allow 5 days for processing
*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.
DCHD (6-82)
r
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from Macedonia Moravian church , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for aground absorption sewage treatment and
disposal system.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and dis al system.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
— Owner only
— Owners designated representative
.max Anyone requesting results
Only those listed below
DATE SIGNATURE
DCHD (11 /84)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
'�t Date ,/)2,���
Lot Size 44:�_rZ
FAC.TORi4 ARFA 1 ARFA 9 ARFA A ARCA A
1) Topography/ Landscape Position
PS
PS
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2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
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3) Soil Structure (12-36 in.)
Clayey Soils
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I) Soil Depth (inches)
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U
U
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i) Soil Drainage: Internal
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S
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External
AS
-
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�) Restrictive Horizons
Available Space
S
SS
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1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
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1) Site Classification
P-
R's—
s'
;-7
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
loo�Aj
Recommendations/Comments: e`Ti
Described by
SITE DIAGRAM
DCHD (6-82(
Title �, Date
7
Parcel #: C700000096
Davie County, NC - Basic Estate Search
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Vieyg Property Record for this Parcel View Mao for this Parcel View Tax Bill Information
Parcel #:0700000096
Account #:46800880
Owner Information
uildin :
Tax Codes
BXF•
ACEDONIA MORAVIAN CHURCH
nd:
ADVLTAX - COUNTY T
arket•
00 NC HIGHWAY 801 NORTH
ssessed:
READVLTAX - FIRE TAX
eferred•
DVANCE NC 27006
Property Information
Township
nd (Units/Type): 12.690 AC
FARMINGTON
ddress: 700 N NC HWY 801
Deed Information
Local Zoning
Pate: 06/1989 Book: 00080 Page: 0184
Plat Book: Page:
Le al Description
PIN
12.23 AC HWY 801
5862771636
Propertv Values
uildin :
1,255,09 0011
BXF•
nd:
204,85
arket•
1,459,94
ssessed:
1,459,94
eferred•
Sales Information
No. Book Page Month Year Instrument Qual/UnQual Improved Price
00080 0184 06 1989 WD Unqualified Improved 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/itsnetfView.aspx?prid=1458793 9/13/2016