389 Liberty Church RdDavie Lounty, NC Tax Parcel Report
Monday, October 3, 2016
I .. .. .. .. T 1 -Ti -E IRL 1911
__.
251
y
/294
1 r
2qi _
2A9
,-�r 175 .
1 3 1A
.'
r l t
1 25,'1
Parcel Number:
E300000119 Township:
Clarksville
NCPIN Number:
...._..ff✓. 3913
__..
Account Number:
_..__..._. ....._.... t _ 7 1
37059-801
Listed Owner 1:
BERGONDO MICHAEL A Voting Precinct:
CLARKSVILLE
Mailing Address 1:
` ,• \ X�; �-., 141.....E irrr
Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A,R-20
,66 4 f
NC Zoning Overlay:
465— 363;''
r
27028 Voluntary Ag. District:
No
JC
11.50 AC LIBERTY CHURCH Fire Response District:
WILLIAM R. DAVIE
Assessed Acreage:
11.50 Elementary School Zone:
WILLIAM R DAVIE
Deed Date:
10/2015 Middle School Zone:
NORTH DAVIE
f
010030395 Soil Types:
F-@]
All data Is provided as la 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
NC or arising out of the use or Inability to use the GIS data provided by this website.
I .. .. .. .. T 1 -Ti -E IRL 1911
__.
251
y
/294
1 r
2qi _
2A9
WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number:
E300000119 Township:
Clarksville
NCPIN Number:
5811659870 Municipality:
Account Number:
8305675 Census Tract:
37059-801
Listed Owner 1:
BERGONDO MICHAEL A Voting Precinct:
CLARKSVILLE
Mailing Address 1:
389 LIBERTY CHURCH ROAD Planning Jurisdiction:
Davie County
City: MOCKSVILLE Zoning Class: DAVIE COUNTY R-A,R-20
State:
NC Zoning Overlay:
Zip Code:
27028 Voluntary Ag. District:
No
Legal Description:
11.50 AC LIBERTY CHURCH Fire Response District:
WILLIAM R. DAVIE
Assessed Acreage:
11.50 Elementary School Zone:
WILLIAM R DAVIE
Deed Date:
10/2015 Middle School Zone:
NORTH DAVIE
Deed Book / Page:
010030395 Soil Types:
MnC2,MnB2
Plat Book:
Flood Zone:
Plat Page:
Watershed Overlay:
DAVIE COUNTY
Building Value:
40420.00 Outbuilding & Extra
Freatures Value:
1140.00
Land Value:
100170.00 Total Market Value:
141730.00
Total Assessed Value:
141730.00
F-@]
All data Is provided as la 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
NC or arising out of the use or Inability to use the GIS data provided by this website.
391"1836Davie County Health Department
Ilenmental Health Section
4]�
P.O. Box 848
210 Hospital Street
4a Courter # : 09-40-06
Mocksville, NC 27028
Phone: (336) - 753 - 6780
ON-SITE WASTEWATER CERTIFICATION
Fax: (336) - 753-1680
(Check One) Replacement Reconnection -296-5-7
Name: a m' do Phone Number(Home)
Mailing Address: 11-10 J Oil Llsog (Work)
` _ odsSIJ1t1) N.(.ylozz Email Address: W1060_AQ'Ado(it ti",, I. (om
t
Property Address: '�R '� Liber 4t" Ck ldrc,� I to od'. ryl or ew-, lle . fu •C - 2407-Z
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: C4 -NC C Type Of Facility: )- Lwylt?.
Date System Installed (Month/Date/Year): "? Number Of Bedrooms:_3_Number Of People:
Is The Facility Currently Vacant? es No If Yes, For How Long?Any Known Problems? Yes &, If Yes, Explain:
Please Fill In The Following Information About The NEW Facility��
x�
Tyre Of Facility:' Q m1i— Gu-, zoom - A'-} 1 a N ,/� Number Of Bedrooms: _k Number of People
Pool Size:I �Ji - Garage ' e: - I f t - Other:
Requested By: Date Requested: I /' �- 1S
For Environmental Health Office Use Only
Environmental Health
Date:
*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.
Check Money Order #.
Paid By: Received By:
Account #: Invoice #: /
cl
2.3 6 Ze-7,
4 \v
Cs,rtc YU401
OQ
. APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT & ATC
Davie County Environmental Health
P.O. Box 848/210 Hospital Street
Mocksville, NC 27028
(336)753-6780/ Fax (336) 753-1680 -/
Application For: 4 Site Evaluation/Improvement Permit C;4 -Authorization To Construct(ATC) rBoth
Type of Application: ❑New System ❑Repair to Existing System ❑Expansion/Modification of Existing System or Facility
IMPORTANT'"" THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATION
Name to be Billed 1, 1 l (�(;- /cw i VYO Contact Person1 e t i
Billing Address 14o —tei."y Home Phone
City/State/ZIP Cyl CVSVille IUC 2-4U'Z79 BusinessPhone` U - -Iwo Xfsoi
Name on Permit/ATC if Different than Above SArVIC' S l�J%)Q
Mailing Addressaf abuUtr City/State/Zip
rttvrr,tct t uvrvKrAAiuviN -nate nouseiracutty t,omers riaggea
NOTE: A survey plat or site plan must accompany this application. Included: �k Site Plan ❑Plat(to scale)
(Permit is valid for 60 months withite plan, no expiration with complete plat.)
Owner's Name MiC(& T>gUnX Phone Number 336 -g36 -17Z24
Owner's Address 14 a' re v Cant' City/State/Zip
Property Address 32q o bc^IN CKkWA &V city mOCi-SV ille
Lot Size 1% V3tfeS Tax PIN#
Subdivision Name(if applicable) AJ 10 : SectioytlLot#
Directions To Site: I11nf44q DN 1�liwra.e lot tri �F�nVil1�( ow4o (+1,tr1t,
If the answer to any of the following questions is "yes", supporting documentation must be attached.
Are there any existing wastewater systems on the site?
Yes ONo
Does the site contain jurisdictional wetlands?
O Yes'dNo
Are there any easements or right-of-ways on the site?
❑ Yes 71No
Is the site subject to approval by another public agency?
❑ Yes %No
Will wastewater other than domestic sewage be generated?
❑ Yes)kNo
IF RESIDENCE FILL OUT THE BOX BELOW
# People I # Bedrooms 3 # Bathrooms I Garden Tub/Whirlpool ❑Yes DANo
Basement: ❑Yes 914o Basement Plumbing: ❑Yes XNo
IF NON -RESIDENCE FILL OUT THE BOX BELOW
Type of Facility/Business Total Square Footage of Building # People
# Sinks # Commodes # Showers # Urinals
Estimated Water Usage (gallons per day) (Attach documentation of similar facility water consumption)
FOODSERVICE ONLY: # Seats
Type system requested: ❑Conventional ❑Accepted ❑Innovative
❑Altemative Other
JX 1 siino,
SISie n'►
Water Supply Type:(County/City Water ❑ New Well
❑Existing Well
❑ Community Well
Do you anticipate additions or exp, a�s.ons of the f ility this system is intended to serve?,)&es ❑ No
If yes, what type? — R FLrrinil� 01'V+ .
m
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand
that any permit(s) or ATC(s) issued hereafter are subject to suspension or revocation if the site is altered, the intended use
changes, or if the information submitted in this application is falsified or changed I hereby grant right of entry to the Authorized
Representative of the Davie County Health Department to conduct necessary inspections to determine compliance with applicable
laws and rules. I understand that I am responsible for the proper identification and labeling of property lines and comers and
locatingAno flagong pr Viking thiphouse/facility location, proposed well location and the location of any other amenities.
1 Site Revisit Charge
Pr representative signature
Date(s):
Client Notification Date:
Date EHS:
Sign given ❑Yes ONo Account #
Revised 11/06 Invoice #