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374 Yadkin Valley RdParcel #: C80000000104 Davie County, NC - Basic Estate Search Basic Search Real Estate Search Tax Bill Search Sales Search � View Pro�ertv Record for this Parcel View Ma� for this Parcel View Tax Bili Information Parcel #: C80000000104 Accou�t #:8300391 Owner Information Tax Codes HENDERSON RICKY A& HENDERSON BRIDGEf B ADVLTAX - COUNTY T 152 S HIDDENBROOKE DRIVE READVLTAX - FIRE TAX DVANCE NC 27006 Pro e Information Townshi Land (Units/Type): 23.810 AC FARMINGTON ddress: 374 YADKIN VAILEY RD Deed Information Local Zoning � ate: 06/2011 Book: 00861 Page: 0036 Plat Book: Pa e: Le al Descri tion PIN 25.400AC YADKIN VALLEY 5872397079 Pro e Values Buildin : 27139 BXF: 3 47 Land: 331 32 Market: 606 18 ssessed: 606 18 Deferred• Sales Information Book Page Month Year Instrument Qual/UnQuai Improved Price 00309 0111 07 1999 WD Unqualified Improved 750,000 00861 0036 06 2011 WD Unaual(fied Imoroved 495.000 View Proaertv Record for this Parcel View Ma� for this Parcel View Tax Bill Information « Return to Basic Search Page 1 of 1 o �M�� �, ^ 1 �� ` -O � �� 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. Ali 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, incfuding without limitation the implied warranties of inerchantability 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:!lmaps.daviecountync.gov/itsnetNiew.aspx?prid=1465380 10/12/2016 � ' � DAVIE COUNTY HEALTH DEPARTMENT ,��'"/� IMRROVEMENTS PERMIT AND CERTIFICATE.OF COMPLETION " 'NOTE: Issued in Compliance with'G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968). Pe�mit Number ;' Name /� , t / <� ,,� �� � �,• ,� Date `�� / � � .� � �:� :i :., kT Location y%J,';r ��� G;? i�:� �;• c i% . i��> Subdivision Name Lot No. Sec. or Block No. Lot Size �� `�G House "j Mobile Home _ Business __ Speculation No. Bedrooms �� No. Baths ��' - No, in Family '� _ Garbage Disposal YES ❑ NO ❑ S ecifications for S stem: �,,.; i: � 7<.� Auto Dish Washer YES �j NO ❑ P - Y /� � 1 �., Auto Wash Machine YES �] NO ❑ ���� x�� �� Type Water Supply l,ti�. � c , —f�i(JX - . �.. � ,� r , . 'This permit Void if sewage system described below is not installed within 36 months from date of issue. , -,..� � -, � � �� �� �.. _-- - __. ._ _ _ \ ! �,� � � _ - _- _ -- _ � 1 � � � � ' . ,�.----_- ---_ --._ _ ....._- �� /� �.. _ ��. _._ -� -- ---_-�--_..____._ _ �� 1 i � . �; , , , , , .__ ` , . �� � _ _ ,�, . j, , _. .�:i ._��r.�,��� ,,- r�..�e�� � ���, �_ . �� ,r � 2'" r7� " ILi n-e s , o iL >;::'♦;�. ,: - 3 !v � ��'1� Improvements permit by •' !.y � r: � J •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 �<<�' �i _%/r���r rz.- _. _--_--- --•-�_. _. � � ,: t;., � Certificate of Completion , -�-' � ��•�` '� _ Date � �� �� ��� `The signing of this certificate shall indicate that the system describe�d 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. 'AU`L.H_[?�Ta A.TION NO: a%��, DAVx� COUNTY HEALTH DEPARTMENT �`,' � il � R����' Environmental Health Section PROPERTY INFORMATION Pemuttee's . i� � P.O. Box 848 Name: f"r�.^; i�/ ���'r': ? y i~ r-1 Mocksville, NC 27028 Subdivision Name: j ; Phone #: 704-634-8760 D'uections to property: r%� • �r Section: Lot: �� AUTHORIZATION FOR WASTEWATER Tax Offi PIN:# - SYSTEM CONSTRUCTION 37� i� %—T C.✓T �a. Road Name: � Ll.� ip: d 7 00 �p **NOTE** This Authorization for Wastewater System Construction MUST BE ISSLIED by the Davie Counry Environmental Health Section prior to issuance of any Building Pemvts. This Fom�/Authorization Number should be presented to the Davie County Building Inspecaons Office when applying for Building Permits. ' (In compliance with Article 11 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. ENVIRONMENTAL HEALTH SPECIALIST DAT'E ISSUED RESIDENTIAI, SPECIFTCAT[ON: BUII.DING T'YPE �� # BEDROOMS �_ # BATHS �_ # OCCUPANCS � GARBAGE DISPOSAL: Yes or No COMMERCIAI. SPECIFICAT'[ON: FACII.ITY 1'YPE # PEOPLE # PEOPLF/SEIIF'T # SEATS INDUS : Yes or No ��� LOT SIZE `//�C TYPE WATER SUPPLY � DESIGN WASTEWATER FLOW (GPD) NEW S1TE REPAII2 STI'E !/� SYSTEM SPECIFICATIONS: TANK SIZE '!�C GAL. PJUMP TANK GAL. TRENCH WIDTH � ROCK DEPTH � LINEAR FT ',�} O _ + .�.Ct� i 1 ,�Gy7 ��G�� f � �. 1J `/_.j �/ ! . �THER a Y REQUII2ED S1TE MODIFiCATIONS/CONDTI'IONS: /""'�!�_ , - /` /1 Sl --- - `�—. , IMPROVEMENTPE ���G OUT�`�,/C�iI✓l� J 1�1i �� /I � S � 3�°� �;�c�� �.O°�' ,� . ro��`'� � �� (�'�� R�� � P r� �r�' r /`� jt, e w .�'" : f r , f �',.%� R�L�ikN�. •'CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN 8:30 - 930 A.M. OR 1:00 -130 P.M. ON TIIE DAY OF INSTALLATTON. TELEPHONE # IS (704) 634-8760. OPERATION PERMIT I SYSTEM INSTALLED BY: ��.�%��W ."�D' � SC i —^ .�----� r-____, II AVI'HORIZATION N0. � OPERATION PERMTf BY: �� DATE: ��D �% "*TF� ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT Tf� SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WTTH ARTICLE 11 OF G.S. CEiAPTER 130A, SECTION .1900 "SEWAGE TREATMENT AND DISPOSAL SYSTEMS", BUT SHALL IN NO WAY BE TAKEN AS A GUARANTEE THAT THE SYSTEM WII.L F[JNGTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OSN6 (Revised) z:� .. ,:. � � . , . .. .4 . � : .:� ; , �..� ., ;:�. '� .:'`.":� � . r. , �'� , r . . . . . �..'.• � .: . �' . .. �. ' . . . . �. .. .r ` 1.. ,.. ; � . . . � . . . . .. i . .. . . . .'' . . . . ; ; ; . , � � • � ���� y • � : "AiJ'�HOR1Z'P.TION NO. �'7 �� �� DAVIE COUNTY HEALTH DEPARTMENT i�� � � Environmental Health Section PROPERTY INFORMATION Permittee's f; :, P.O. Box 848 Name: :�"i .r'.� i� f:"': �"'>' �;' y'` :.•f Mocksville,.NC 27028 Subdivision Name: ` � '�`'� ; �, Phone #: 704-634-8760 Directions to property: �r`' '+'% � rf Section: Lot: f' AUTHORIZATION FOR WASTEWATER Tax Offi PIN:# SYSTEM CONSTRUCTION � 7� i� % � Road Name: � L� ip 7 Ol9 **NOT'E** This Authorization for Wastewater System Construction MUST BE ISSUED by the Davie County Environmental Health Section prior to issuance of any Building Pernuts. This Form/Authorization Number should be presented to the Davie County Building Inspections O�ce when applying for Building Pernuts. � ' (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTTCE*** THIS AUTfIORIZATION FOR WASTEWATER CONSTRUCTION ^' F.' <:" ;"r`f � LS VALID FOR A PERIOD OF FIV� YEARS. ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED r { �� ' '�� .�:.. ...�s , � �4 � � � t;4� " '' �`�`� ����• = DAVIE COUNTY HEALTH DEPARTMENT ' � � ' ��' �'�'�''� � �� � T"'� " ' ` -IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION :Permittee's ;,� �,,., Name: ` :�> .�� P . r,r;'r�',.•� �`.r . _. ._ • ._. ;.. � � , Directions to property: j�.= �'' Fy, 1'; i� - ,' � IlVIPROVEMENT PERMIT � Subdivision Name: Section: Lot: Tax•Office PIN:# - - ,..� , � ` y �r� Gl1- �cL - Road Name• /)/�'k,'/!� Vi"�l-L.�S�Zin: c�' �0 **NOTE** This Impmvement Pernut DOFS NOT authorize the construction or installation of a septic tank system or any wastewater system. An AUT'HORIZATION FOR WASTEWATER SYSTEM CONSTRUCfION must be obtained from this Depardnent prior to the construction/'�nstalla6on of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) `/ ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF SITE (i': � `„> ;�`"�. :. `,''',"' %1` '!; , r'%' PLANS OR TEIE IlVTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE THI.S PERNIIT BEFORE INSTALLING THE SYSTEM. RESIDENTIAL SPECIFTCATION: BUILDING TYPE �# BEDROOMS ��'� # BATHS __r ,�< # OCCUPANTS '--%� GARBAGE DISPOSAL: Yes or No COMMERCIAL SPECIFICAT'ION: FACILITY TYPE # PEOPLE # PEOPLFJSHIFf # SEATS INDUSTRIAL WASTE: Yes or No LOT SIZE �/ %j� TYPE WATER SUPPLY /�% DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE l�r / • �! � ( SYSTEM SPECIFICATIONS: TANK SIZE/ •�'�G' GAL. �UMP TANK r GAL. TRENCH WIDTH ��+' ROCK DEPTH . 3�'` LINEAR FT.;1 l� � �—, i. �J A � � � `%...� . �� /S.L� I� ` . �Y / % p�G/„' i: I?.(' ' �� �/ OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT�`��iNGj � � � o'����� � 'S '� 1 G'�% "� � o� ..--- �� 1 3 �� �� � �l �... q r�h�`'� � �a (�'�� �� � �_ _ ,��� p ;l� R �P! %'� it� P- i,v 1,_,r. .� r'�s "'"� {�ii � 11: c� r� **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. T'ELEPHONE # IS (704) 634-8760. OPERATION PERMIT SYSTEM INSTALLED BY: ��.�i�ii�6fiZ�' r- AUTHORIZATION NO. �� OPERATION PERMIT BY: �� DATE: ��0 �% **THE ISSUANCE OF THIS OPERATION PERMiT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE WTfH 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 WII.L FUNCfION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. DCHD OS/96 (Revised) ; . . , :: . .. , ... __-. ;., , ,;, ,: . __ ! __ . . . , _ . M),� vr 'f1 ' , � � �� �;'�) : � `�%.' � . DAVIE COUNTY HEALTH DEPARTMENT + ' � �� � ' `�='`�" ,.. ;--. - ,. :rd ; '� — --� � ��. �.� �- � -IMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION Permittee'.s � Name: ' ��;, , , , � � r : � � . J • ,., t _ .. _ ,� Directions to property: � � %� � � �'� IlbIIPROVEMENT PERMIT Subdivision Name: Section: Lot: Tax�.?�ce PIN:# - - .:.% i 4 � / 7 �� Road Name• ,; .r <,, . / � � �7 , � .- � r�ip. **NOT'E** This Improvement Pernut DOES NOT authorize the constcuction or installation of a septic tank system or any wastewater system. An AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTTON must be obtained from this Department prior to the construction/installation of a system or the issuance of a building pernut. (In compliance with Article 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems) ***NOTICE*** THIS PERMIT IS SUBJECT TO REVOCATION IF S1TE ,,;a�''* PLANS OR THE INTENDED USE CHANGE. YOUR WASTEWATER ENVIRONMENTAL HEALTH SPECIALIST DATE ISSUED SYSTEM CONTRACTOR MUST SEE TI-IIS PERMIT BEFORE INSTALLING TI� SYSTEM. RESIDENTIAL SPECIFICATION: BUII..DING TYPE �# BEDROOMS �`` # BATHS _ t,�� # OCCUPANTS � GARBAGE DISPOSAL: Yes or No . COMMERCIAL SPECIFICATION: FACILTTY TYPE # PEOPLE # PEOPLFJSHIFT # SEATS INDUSTRIAL WAS7'E: Yes or No LOT SIZE •���%f� TYPE WATER SUPPLY *=rrll r"%I DESIGN WASTEWATER FLOW (GPD) NEW SITE REPAIR SITE ��-'"� —, �� ` � � � SYSTEM SPECIFICATIONS: TANK S1ZE =,��'f' GAL. PUMP TANK GAL. TRENCH WIDTH .5 %� ROCK DEPTH �^7 `%� LINEAR Ff.�j (�% l/ ,�}.;��;�.•6,t.t�,, l/��,;:��� -- ,��i �,!:;;�, OTHER REQUIRED SITE MODIFICATIONS/CONDITIONS: IMPROVEMENT PERMIT LAYOUT ! fl� �/(� �, 1�� � �. ' 9C�` �+ �'. � �d �pM1�1 t� r ��'} - ��'`` �-n �� -' �}1l(l�i 1 1 � I ��1 � ���� � �r�d, �� �� �� ��� f; �: � ,,,.,...-....,-.,. � ,,.•........,.�.-�� �_----�..�i %`�, r:l �: r.,v „1_. �-�.�, •'�; �;'"" �^ J �:��;;;�.«�� **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 - 130 P.M. ON THE DAY OF INSTALLATION. TELEPHONE # IS (704) 634-8760. I OPERATION PERMIT SYSTEM INSTALLED BY: �� ��- Y" ,: ��� , .a,�,,,,.,,.,!�_�...-.�....,......� .,�,..,,.�.r..�...� G AUTHORIZATION NO. �'�'!�'� OPERATION PERMIT BY: S'�f ,�'f DATE: �_��T t'-� / **THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM 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 OSN6 (Revised) _ . _,. . . �' � DAVIE COUNTY HEALTH DEPARTMENT ' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)r Permit Number Name j'�-/; , �:�; � r, � .r�° �_� Date ��`� ! � �' - • , . .., . . . :�,,.. rt e.. ;; ., Location �'/t �; �-�"� r✓ l� i' � ; : ; - C � % . , ° „ Subdivision Name Lot No. Sec. or Block No. Lot Size �� �1 House '''�y Mobile Home ____ Business _— Speculation No. Bedrooms �"� No. Baths = S'��_ No. in Family ��� _ Garbage Disposal YES � NO ❑ � Specifications for System: /r�' c`�.� ��:.:'i: � f-�� h Auto Dish Washer YES 0 NO 0 � , �l` Auto Wash Machine YES 0 NO 0 .�� C � i' �> a; ,: ; . r : Type Water Supply (.1�;r � c.. --- 1� - t.� _�', �' !.; s�-; c �< F�; <� `This permit Void if sewage system described below is not installed within 36 months from date of issue. % � � � --. .��`'`� � � ~�'�\ ; lt ''� _ _, _..___--------_______ .,� \� 1 ��� --' _--.—.-.____._____ '\ �;1 1 �`',1 ,\ y _. _,.--, Jr f Jr „ '" �._ -�._-.� `�, i � � � 1 �: �'-�= �� �1 ( ',\ �.�.�__-"---- _....._ ._....`_._-._._��� 1 � � � `� .,\. � ``�'—�___�___-__--- _ ��, (� j'' �:ic�� t, _f !%:(lC:��,�� /1• !"-'�...�r�l� l c7! � i:'�, , t.� �, (� 1' i Il r . � � � � . i '`, r.—`._' _- t '1 . � �l._-.�_�"" `—. �'. � �_ 5 � i 1' 1, i - C�1 l �. �� . ���;�� ' C�i.i. S Improvements permit by � ' � " -- f -- .— "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 compietion. Telephone Number: 704-634-5985. i'ii,.(� �` � 11i.%•��t:�.� Final installation Diagram: System Installed..by �—'� _,� � -�. ., \ ', �, "� .,,, ,, \ \ �, �. ' �'` � �1 ,, t `, --__._.__"..._---_._�.._.__,.._.__.__._._._..--^-� ��_ ��.✓''/J � •� ' _ _� 7 `-----_�..—'---------.._......_....._._...,_.... _i T i f � �•�� �_i'-i s � Certificate of Completion __ � Date % �� - -� "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 �aken as a guarantee that the system will function satisfactorily for any given period of time. ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION � Name � - ' ` ���' "' "�7 Address 26S � 6LEN �ort-� !�-S Nc 1) Topography/Landscape Position 2) Soil Texture (12-36 in Sandy, Loamy, Clayey, (note 2: ay) 3) Soil Structure (12-36 in.) Clayey Soils 4) Soil Depth (inches) 5) Soil Drainage: Internal External 6) Restrictive Horizons 7) Available Space 8) Other (Specify) 9) Site Classification AREA 1 � � U S PS U � U � U � U � U S PS U I`� S AREA 2 � U � U S PS U S � U i �� � U � U S PS U Date � '� � �� Lot Size S US PS U S PS U S PS U S PS U S US S PS U S PS U AREA S US PS U S PS U S PS U S PS U S US S PS U S PS U U—UNSUITABLE S—SUtTABLE �S � Provisionaliy Suita— b j '( �N � � '�' �� �` Recommendations/Comments: .-- Described by —�+�'"�^�' Title�N'`�2�� Date 3-7 —�! 3 SITE D�AGRAM DCHD (6-82) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section ,/ � P. O. Box 665 (p3ys 9a � Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone g19-765-1034 1. Permit Requested By Ray L. Gentry Business Phone g 19 — 9 9 8— 6 8 0 0 2. Address 2 6 51 Glen Fore st Drive — Winston— Salem , N. C. 3. Property Owner if Different than Above Bert Bahnson Address 4. Permit To: a) Install X Alter Repair b) Privy Conventional X Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House X Mobile Home Business Industry Other b) Number of people 2 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 112' x 40' Bed Rooms 3 Bath Rooms 3 2 Den w/Closet 1 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 4 urinals , lavatory 5 showers 3 dishwasher 1 sinks � garbage disposal 1 washing machine 2 8. a) Type water supply: Public Private X Community b) Has the water supply system been approved? Yes No X 9. a) Property Dimensions 4 5 0' X 14 0 0' — Average — 17 Acre s b) Land area designated to building site NPAroximately Center of Property . c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? No What type? Th' is to ertify that the information is correct to the best o m n edge. �3 Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: DCHD (6-82) DAVIE COUIQTY HEALTIi Dr,PARTIIEIIT SITE EVALUATIOI�1 COidSEITT F'QRM INSTRUCTIOT7S/P12EREOUI S TES l. Cc�mple�e th� fcrm b�low and raturn it ico the Davi� C�. Health D�partm�nt. 2. Along with �ch� f�rm, remit the amaunz due as shown �n encl�sed statarnenz. 3. Garefully fellaw the proce�urss as outlined in �he �nclos�d `°Infarmaiian Hulletin". 4. Ydotify Healich Department up�n c�mple�ion af iz�m nur�b�r 3. NOTE: ALL THL ABOVE T�U5T BE DOPdE BEFORE A SANITARIAYd �tiILL BE ABLE TO �3EGIP7 THE E2EQUEST�D EVALUATIOP7. DETACH HERE AND RETURYJ 7'0 TEiE(DAVIE COUiJTY HEALTH DEPAR�rIE�TT,P.O. �30X 57) (t�40CKSVILLE, 1V.C. 27028) LOCATIOi�3 OF PROPERTY : DAVIE CaUNTY HEALTI: DEPARTT�'iENT SITE EVALUATIOPa COYJSEN''i' FOtiPI Part of Bahnson Farm - Left of Yadkin Valley Road Approximately 3,000 feet NE off of 801 � DATE REC�IVED (offi�e use only) yes no (1.) I am i�he cwncr of the ab�ve describ�d property. �� �� i._� � y2s no (2.) I�m not the cswn�r of zhe abava describ2d propericy, hawev�r, I �� I cartify that I have cons�nt fr�M Bert Bahnson ,dwner to ' =.,! �� cswn �r' s narn� obtain a site evaluaticn by tha healih Department for the purpose c�f determining tha suitability far a graund absorptic�n sewage disposal syst�r3. yes o(3.) I harsby givc c�nsznt ico the authariz�d repr�sentativ� of the ! F Davie Caunty H�altn Dapartm�nt tc �n�er up�n th� ab�ve d�scribed �_ l..__� praperty and ccnduct all t�5�ing prcceduras necessary to determine its suitability for a gr�und absorpti�n sewage disposal system. 3 7" 2� „�5' DATE �_ SIGNATURE (4.) I h�r�by authorize tha Davis Counicy H�alth Department zo release si�� evaluazion results frcm tne abav�: described prop�rty to the follcwing: �. Owner Only � Owner's designated reprFs�ntative �� (� Anyane requ�sting results i�—'� � Only thmse Iisted bsZow Bert Bahnson �2651 Glen Forest Drive Ray L. Gentry Winston-Salem, NC 27103 � DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION WORKSHEET FOR SEPTIC SYSTEM REPAIR PERMIT NAME n PHONE NUMBER ��'�,��% ADDRESS �'� G. J� �� yZ� SUBDIVISION NAME ��✓vA��. ��11��� SUBDIVISION LOT # DIRECTIONS TO SITE DATE SYSTEM INSTALLED 1��� � NAME SYSTEM INSTALLED UNDER ,� SPECIFY PROBLEMS OCCURRING DATE REQUESTED INFORMATION TAKEN BY