2496 Liberty Church Rd 3avie County, NC Tax Parcel Report Tuesday, September 27, 201 f
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1775\
2566
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2544
2573 2496
- - —` 249}3
2479 2471 J 2468 2462
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WARNING: THIS IS NOT A SURVEY
sInforination
Parcel Number: B20000000408 Township: Clarksville
- NCPIN Number: 5803694567 Municipality:
Account Number: = Census Tract: 37059-801
Listed Owner 1: Voting Precinct: CLARKSVILLE
Mailing Address 1: Planning Jurisdiction: Davie County
City: Zoning Class: DAVIE COUNTY R-A,R-20
State: Zoning Overlay:
Zip Code: Voluntary Ag.District: No
Legal Description: Fire Response District: LONE HICKORY
Assessed Acreage: 10.83 Elementary School Zone: WILLIAM R DAVIE
Deed Date: / Middle School Zone: NORTH DAVIE
Deed Book/Page: Soil Types: MnC2,MnB2,MdE
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: Outbuilding&Extra
Freatures Value:
Land Value: Total Market Value:
Total Assessed Value:
All data is provided as is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the
County of Davie,North Carolina,its agents,consultants,contractors or employees from any and all claims or causes of action due to
�DUN�� NC or arising out of the use or inability to use the GIs data provided by this website.
For Office Use Only
HEALTH DEPARTMENT RELEASE
*CDP File Number 230481 - 1,
Davie County Health Department
1f 210 Hospital Street County ID Number:
Box 848 P.O.
HDRMWC
Evaluated For.
Mocksville NC 27028
Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 9 / a 6 / a 0 a 1
UNTIL
Applicant: Chasity Robertson Property Owner: Chasity Robertson
Address: 2496 Liberty Church Rd Address: 2496 Liberty Church Rd
City: Mocksville City: Mocksville
State2ip: NC 27028 State0p: NC 27028
Phone#: (704)746-6133 Phone#: (704)746-6133
Property Location&Site Information
Address2496 Liberty Church Road _ Subdivision: Phase: Lot
- - Road# Yadkinville NC 27055 -
SINGLE FAMILY Township:
'Structure: Directions
#of Bedrooms: 3 #of People: Hwy 601 North Left on Liberty Church Road.house on left
'Water Supply: PUBLIC
Type of Business:
Basement: n Yes�No
Total sq.Footage: No.Of Employees:
"Proposed Improvement:
Remodeling Home
*Release Conditions `
Maintain 5 foot setback to any poertion of the septic system. I
This release in'no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps.Signature Required? Oyes ONo
Applicant/Legal Reps.Signature; *Dated
*Issued By: 2140-Nations,Robert *Date of Issue: 0 9 / 2 6 2 0 1 6
Authorized State Agent:
**Site Plan/Drawing attached.**
U Hand Drawing Olmport Drawing
HEALTH DEPARTMENT RELEASE
sra Davie County Health Department CDP' File Number: 230481 - 1
210 Hospital Street
P.O.sox 848 County File Number:
J Mocksville NC 27028 Date: 09 / 2 6 / 2 0 1 6
QWA
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Scale: OBlock = .ft.
Drawing Type: Health Department Release ON/A
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Page 2 &Y
CONSTRUCTION For Office use Only
AUTHORIZATION *CDP File Number, 230481 -1
Davie County Health Department
County ID Number:
210 Hospital Street Evaluated For HDRMWC
P.O. Box 848 Township::
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 9 / a 6 / a 0 a 1
Applicant: Chasity Robertson rAdd
roperty Owner: Chasity Robertson
Address: 2496 Liberty Church Rd ress: 2496 Liberty Church Rd
City: Mocksville City: Mocksville
State2ip: NC 27028 StatefZip: NC 27028
Phone#: (704)746-6133 Phone#: (704)746-6133
Property Location & Site Information
CYaAddress/Road#: Subdivision: Phase: Lot:
96 Liberty Church Road
dkinville NC 27055 Directions
Structure: SINGLE FAMILY Hwy 601 North Left on Liberty Church Road. house on
left
#of Bedrooms: 3
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a �
rSitessification: Provisionally Suitable Inches
Minimum Soil Cover. 1 a
System? OYes ONo Inches
Design Flow: 3 6 0 Maximum Trench Depth: 3 6 Inches
Soil Application Rate: 0 2 7 5 Maximum Soil Cover: a 4 Inches
'System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A CONI SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank:
�. Gallons
*Proposed System: 25%REDUCTION 1-Piece: Oyes ONo
Pump Required: OYes ONo OMay Be Required
Nitrification Field
Sq. ft. Pump Tank: Gallons
No. Drain Lines 1-Piece: OYes ONo
Total Trench Length: a 0 0 ft GPM—vs— ft. TDH
Trench Spacing: _ 9 Onches
Fe t O.C.O.C. Dosing Volume: _ Gallons
Trench Width: Inches
3 Feet Grease Trap: Gallons
Aggregate Depth: - -
inches Pre Treatment: ONSF OTS-1 OTS-II
Septic Tank Installer Grade Level Required: 01 011 0111 OIV
D,m~% 4 ^f'A
CDP File Number 230481 - 1 County ID Number. ,
❑ Open Pump System Sheet
Repair System Required:OYes ONo ONo, but has Available Space
rDesign
system
Trench Spacing: Q Inches 0.
ification: Q Feet O.C.
Trench Width: Inches
w: — Feet
Soil Application Rate: Aggregate Depth: inches
*System Classification/Description: Minimum Trench Depth: Inches
Minimum Soil Cover. Inches
Maximum Trench Depth:
*Proposed System: Inches
Maximum Soil Cover:
Nitrification Field Inches
Sq.ft.
No. Drain Lines *Distribution Type:
Total Trench Length: - ft Pump Required: QYes ONo OMay Be Required
- Pre Treatment: ONSF OTS-1 OTS-11
- "Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
*Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization for Wastewater System Construction shall be valid fora person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be Issued at the same time the improvement Permit issued(NCGS 130A-336(b)}If the installation has not been
completed during the period of validity of the Construction Permit,the information submitted In the application for a permit or Construction
Authorization is found to have been Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become
invalid,and may be suspended or revoked(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicant/legal Reps. Signature Required? QYes ONO
Applicant/Legal Reps. Signature• Date:
*Issued By: 2140-Nations,Robert Date of Issue: . 0 9 / a 6 / a 0 1 6
Authorized State Agent: Malfunction Log OYes .'
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 230481 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 9 / .2 6 / .1 0 1 6
Q Inch
Drawing Drawing Type: Construction Authorization Scale: , 081ock
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CONSTRUCTION AUTHORIZATION .
Davie County Health Department
210 Hospital street CDP File Number: 230481 - 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: 09 / 26 / 2016
Click below to Import an Image from an external location: Drawing Type:Construction Authorization
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Davie County Health Dep'c tnient
4'1; " Environmental Health Section
.� 10 P.O.Box 848 k
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210 Hospital Street
1
. Q ZT �'S Courier# : 09-40-06
Mocksville,NC 27028
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Phone:(336)-753-6780 F=(336)-753-1680
- ON-SITE WASTEWATER CERTIFICATION
- (Check One) Replacement Remodeling Reconnection
Name: Q�l Phone Number ��Y'" /�tlJ '&/! `(Home)
Mailing Address: ��� (Work)
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Detailed Directions To Site: / G_X_P (y Q/ A"Dr-&-1 'f O )24A�W/ [,/. - -<
• r. __
Property Address: g l L.//
Please Fill In The Following Information About The EXISTING Facility - a7G� S
Name System Installed Under: Type Of Facility:
Date System Installed(Month/Date/Year): Number Of Bedrooms: Number Of People:p _.
Is The Facility Currently Vacant Yes No If Yes,For How Long?_
Any Known Problems? Yes No If Yes,Explain: j? 2 C
o /? - no
Please Fill In The Following InformLatio�n�About The NEIV Facility:
Type Of Facility: 92,QZ cemZIC.0(� / 0/np Number Of Bedrooms: Number of People_
Pool Size •// Q Garage Size:_ /�-� Q Other:.
Requested By: (' Date Requested: -5z l(o
(Signature)
For Environmental Health Office Use Only
Approv d Disapproved
Comments: ✓ �� ��
�l� S s
Environmental Health Specialist Date: q `�
*The signing of this form by the Environmental Health Staff is in 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: CashChec Money Order # 0 3 Amount:$ /00-0 Date:
Paid By: 2,�(' Received By:
Account#: oq 367 V Invoice#:
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