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DAVIE COUNTY HEALTH DEPARTMENT 3
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ?�r
71- *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 1 OA. }1 934-.1968) Permit Number
.lame �1�r_t�C'_�� �,��� - Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile;Home Tt/ Business'' Speculation
..
No. Bedrooms ' No. Baths' _ Family r' �� V
No. in
Garbage Disposal YES ❑ NO p/
Auto Dish Washer YES p NO ❑ Specifications for System:
Auto Wash Machine YES Ell NO ❑ �
Type Water Supply _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by���`
\\ Certificate of Completion \ '� Date—L- -5 I "
'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/IMPROVEMEN PV6
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
1. Permit Requ $t By �Pn�F�n�h��jS �,c��� Business Phone o�I�
2. Address
3. Property Owner if Different than Above e s e G r e
Address v gra ( uc„c 7 0 9 a
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lotr,�, nes S yam"
5. System used to serve what type facility: House Mobile Home Business r.
0 Industry. Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms. 1f k4k
House Dimensions
Bed Rooms D Bath Rooms Den w/Closet fi
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 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private ✓ Community
b) Has the water supply system been approved? Yes Nom
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner gnature 61
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
k A- kv►XA_
G
144,ts "..P/ w�t..v� pk...: 4'.—_V6 'e"..G-'-7....Q .k A- e40-- "x-Z-Vc
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)
es 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 , owner to obtain a
owner's name
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground 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 disposal system.
DATE
SIGNfATURE (7,
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
Anyone requesting results
— Only those listed below
DATE SIGNATURE
DCHD (11 /84)
c
Name_
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
6
4E
b
S
Lot Size
U
ft
"kr–
FACTnRS ARF A 11 ARFk1 9 J ARFA 3 APPA A
1) Topography/ Landscape Position
S
4E
S
PS
S
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
ds -1
S
PS
S
PS
U
U
U
U
3) Soil Structure (12-36 in.)S
Clayey Soils
S
`5
PS
S
PS
U
U
I) Soil Depth (inches)
S
P
S
PS
S
PS
U
U
U
i) Soil Drainage: Internal
S
—C1
S
U
S
PS
U
S
PS
U
ExternalS
pg
PS
PS
S
PS
U
U
U
U
i) Restrictive Horizons
Available Space
PS
\P
7711
S
PS
U
S
PS
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
1) Site Classification
U-1
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6.82)
S—SUIIAB6&-J
onally Suitable
� 1�1
Title Date -
pubic (gouutg Pcult4 Pepartmeut
unb Pottle pcult4 '�geurg
P. O. BOX 665
gocksbille, North ( arolina 27028
CONNIE L. STAFFORD. SA, MPH
Health Director
Deneil Robbins Burgess
Rt. 7, Box 175
Mocksville, NC 27028
Dear Mr. Burgess:
August 27, 1987
As per your request, a representative from this office visited
your site on August 26, 1987, to determine the soil/site suitability
for the installation of a ground absorption sewage system. Fortunately,
the site is suitable for the installation'of a ground absorption sewage
system.
If you have any questions regarding this site evaluation, please
feel free to contact this office.
Sincerely,
Charles Little, R.S.
Environmental Health
Enclosure
CL/wd
TELEPHONE
(704) 634-5985
(704) 634-5881
Parcel #: 060000003405
Davie County, NC - Basic Estate Search
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View Property Record for this Parcel View Man for this Parcel View Tax Bill Information
Parcel #: 060000003405
Account #: 11568000
Owner Information
BXF•
Tax Codes
Land:
BURGESS DENEIL ROBBINS
Market:
ADVLTAX - COUNTY T
ssessed:
240 US HIGHWAY 601 SOUTH
Deferred:
FIREADVLTAX - FIRE TAX
OCKSVILLE NC 27028
Property Information
Township
Land (Units/Type): 6.540 AC
JERUSALEM
ddress: 4240 S US HWY 601
Deed InformationLocal
Zoning
ate: 11/1987 Book: 00141 Page: 0059
Plat Book: Page:
Le al Description
PIN
51 AC HWY 601 LOT 6
5754215442
Property Values
Building:
49 06
BXF•
01
Land:
57 83
Market:
106 89
ssessed:
106 89
Deferred:
Sales Information
L1No. Book Paye Month Year Instrument Qual/UnQual Improved Price
00141 0059 it 1987 WD Unqualified Vacant 8,000
View Propertv 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/itsnettView.as.px?prid=1474722 7/14/2016