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AUTHORIZATION No: DAVIE`C+OUNTY HEALTH DEPARTMENT b ✓}CO
169 ',
Environmental Health Section PROPERTY INFORMATION
Permittee'S P.O:Box 848
J.1 Vie
"Nattte. Mocksville,NC 27028
Subdivision Name:
k.Fit
Phone# 336-751-8760. ,
Directions to property: Section: Lot:
AUTHORIZATION FOR
i tfc WASTEWATER Tax Office PIN:#�
SYSTEM CONSTRUCTION
r�
Road Name: 3-app t0 �uy) i5 Lip:
~ **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 applyinfor Building Permits.
(In compliah e ith�Article 1 I f G.S.'Chapter 130A;Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
***NOTICE***THIS AUTHORIZATION FOR WASTEWATER CONSTRUCTION"
IS VALID FOR PERIOD OF FIVE YEARS.
E N V I R 0 KM#411A L"-N ALTH PE IST DATE SSU D.
r"f✓�i "bc „P^4i1` 11P�,rc�a4�.r, n w.*r L «.r -..a...,rslw�:rxv�..,t�-t.�....,:-�..e:�.:•+�:.-,�'s..� i'1 C'Y:. r .. �. ...�+r`.�.,.. .. ..�.F
DAME OUNTY HEALTH DEPARTMENT
• . _ �=' ` "�
IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
` `Permittees
NaI'llme - t Subdivision Name:
D sections to property: ` ``''r Section: Lot:
�•=
IMPROVEMENT.. _ L1-
1 '4 s fi , Ir K. � +i f ' PERMIT Tax Office PIN:#
33 tO i6� e Zi ��`v
.. Road Name. :I P:
**NOTE**This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system.Ari
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 11J6f G.S.Chapter 130A,Wastewater Systems,Section.1900 Sewage Treatment and Disposal Systems)
<` •- "^, a� ***NOTICE***THIS PERMIT IS SUBJECT TO REVOCATION SITE
PLANS OR THE INTENDED USE CHANGE.YOUR WASTEWATER
ENVIRON �>,I H LII#SP IALIST DA ISS D SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICATION:BUILDING TYPE #BEDROOMS #BATHS--I—#OCCUPANTS---/—GARBAGE DISPOSAL:Yes oio
COMMERCIAL SPECIFICATION: FACILITY TYPE, #PEOPLE #PEOPLE/SHIFT #SEATS INDUSTRIAL WASTE:Yes or No
1
LOT SIZ kTYPE WATER SUPPLY��T DESIGN WASTEWATER FLOW(GPD)'�� NEW SITE / REPAIR SITE
SYSTEM.SPECIFICATIONS: TANK SIZE _GAL. PUMP TANK' GAL. TRENCH WIDTH_ ROCK DEPTH Z LINEAR FT.
t
OTHER
i
.'REQUIRED SITE MODIFICA TIONS/CONDITIONS:
0dZ
IMPROVEMENT PERMIT LAYOUT,
At
lol
�1LL C bIN rQC.X 10
OQ `
—10
fj
0
! Slam PutLOo �D
r WT3J1�D�
**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 THE DAY OF INSTALLATION.TELEPHONE#IS (336)751-8760.
OPERATION PERMIT (� ` ,
SYSTEM INSTALLED BY: 144/0�'i M�L t-a1L
V5
o�
x cs�'�✓
5 x -
:..IBM
,IW
AUTHORIZATION NO. OPERATION PERMIT BY. ' DATE: 2
-*THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE S S DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE 11 OF G.S.CHAPTER 130A,SECTION.1900"SEWAGE TREA71 E D DISPOSAL SYSTEMS",BUT SHALL IN NO WAY BE AS A
GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME.
DCHD 05/96(Revised)
APPLICAT►QN r-P-9 Si'i EVALvATION/IMPROVEMEM PERMIT&ATC
Davie County Health Department SEP 14 I
Environmental Health Section
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028 ENVIRONMENTAL HEALTH
(336)751-8760 DAVIE COUNTY
t
***ZHPORTANT*** THIS APPLICATION CANNOT BSE PROCESSED UNLESS ALL THE REQUIRED
INF'O'RMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
1. Name to be Billed V Contact Person �1 -1/
Mailing Address 44 P (/ Home Phone la q, oZ d oc1,
City/state/ZIP c �l/ Business Phone
2. Name on Permit/ATC if Different than Above
Mailing Address City/sate/Zip
��QQ,,��DD�L
3. Application For: El Site Evaluation ImProvment Permit/ATC 0 Both
4. system to service: {� House ❑ Mobile Home ❑ Business ❑ Tn0zstry ❑ Other qq��
5. If Residence: People I # Bedrooms &. # Bathrooms tJ
0 Dishwasher 0 Garbage Disposal 0 Washing Machine 0 Basement/Plumbing 0 Bti.em-r'L/No Plrmbing
6. If Business/Industry/Other: Specify type # People
# Commodes # showers # Urinals el Fz
ter Coole:;:;s
ice' FOODSERVICE: # Smats halt. vhmpa�e ..tz'.5,+!+ nem eav,
7. Type of water supply: R County/City V Hell ❑ Community
e. Do you anticipate additions or expansions of the facility this system is intended to serve? I�Yes ❑No
If yes,what type? \�' ftt' x/ w71 h1ome- n h e Y; �
***IMPORTANT***CLIENTS AIUST COMPLETE THE REQUIRED PROPERTY INFORMATION REQUESTED
BELOW. Either a/PLAT or/SITE PLAN AIUST BE SUBMITTED by the client with THIS APPLICATION.
Property Dimensions: CY / Y� l S 3 WRITE DIRECTIONS(from Mockn ille)to PRC:?ERTVK
Tax Office PIN: # A �,c.ox
Property Address: Road Name 3397 SCS �64 I 58
City/Zip nRo cks u d le NC a7CQ'2
If in a Subdivision provide inform2tion,as follows: ���'k - .2L4Ltk'_
Name: n
Section: Block: Lot: Date Property Flagged:
This is to cc.tify that the information provided is correct to the best of my knowledge. I understand that any permit(s)
issued hereafter are subject to suspension or revocation,if the site plans or intended use change,or if the information
submitted in this application is falsified or changed. I,also,understand that I am responsible for all charges incurred from
this appliea,9m I,he;b j,give consent to the Anthorized Representative of the Davie County Health De artm t
to enter upon above described property located in Davie County and owned by s d F b /G+j Q N
to conduct
all testing procedures as necessary to determine the site sui bilih. /, l
DATE SIGNATURE W'
THIS AREA MAY BE USED FOR DRAWING YOUR SITE PLAN(Ir;r.".�.�a all of the following: Existing and proposed
property lines and dimensions, structures, setbacks, and septic lor&-.;ons).
6 9-�
Account No. /
Revised DCHD(07/98) Invoice No. 7a
x
Gv�Sa-�. �o cls viii:
� _ 376A,C w'4 IPAL ,a
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20C I; 0 320 .' 428 _ r 4 Jc
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100 100 1IA.
00 0 t
34 33 3 1 5 ... :i; a
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rn
100 �A ( 0 I114
In • fj7•��. .� *t
-;69.96X 25,
y ti63
r `° X23 0 25
`" 64 (4.74) .
5 32Ao2
596.58
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Parcel#: F600000061 Page 1 of 1
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Parcel#: F600000061 Account#: 82519377
Owner Information Tax Codes
KEATON GARY WAYNE ADVLTAX-COUNTY T
104 HUFFMAN ROAD FIREADVLTAX-FIRE TAX
MOCKSVILLE NC 27028
Property Information Township
Land (Units/Type): 0.350 AC FARMINGTON
ddress: 3398 US HWY 158
Deed Information Local tonin
Pate: 08/2002 Book: 00433 Page: 0771
Plat Book: Page:
Legal Description PIN
1 LOT HWY 158 LIFE ESTATE 5850581953
Property Values
Building: 17,4701
BXF• 01
Land: 12 26
Market: 2973
Assessed: 29 73
Deferred:
Sales Information
No. Book Paye Month Year Instrument Qual/UnQual Improved Price
1 00433 0771 08 2002 WD Unqualified Improved 500
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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.aspx?prid=1459414 6/15/2016