1195 Junction Rd, 195 Delanos Ln Lot 10Davie County, NC, I Tax Parcel Report Tuesday. January 3. 2017
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage;
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
WARNING: THIS IS NOT A SURVEY
COOLEEMEE
Parcel Information
SOUTH DAVIE
M401 OA0010
Township:
Mocksville
5726910168
Municipality:
DAVIE COUNTY
82516538
Census Tract:
37059-801
SPILLMAN ROGER P
Voting Precinct:
SOUTH CALAHALN
PO BOX 738
Planning Jurisdiction:
Davie County
COOLEEMEE
Zoning Class: DAVIE COUNTY R -A R-20
NC
Zoning Overlay:
DAVIE COUNTY CZOD
27014-0000
Voluntary Ag. District:
No
LOT 10 GRANT HEIGHTS 1.590 ac
Fire Response District:
COOLEEMEE
Land Value:
Total Assessed Value:
1.58 Elementary School Zone:
COOLEEMEE
12/2013 Middle School Zone:
SOUTH DAVIE
009450577 Soil Types:
GnB2
0006 Flood Zone:
158 Watershed Overlay:
DAVIE COUNTY
Outbuilding & Extra
Freatures Value:
Total Market Value:
QAC l�, All data is prodded as is without warranty or guarantee of any Idnd either expressed or Implied Including but not limited to the
i Davie County, Implied warranties of merchantability or fitness for a particular use. All users of Dade County's GIS website shall hold harmless the
County of Dade, North Carolina, its agents, consultants, contractors or employees from any and all claims or causes of action due to
I DUN'S
NC or arising out of the use or Inability to use the GIS data prodded by this website.
'_A.U3 H10RIZ ATION NO: ` 2 4 DAVIE C�UNTY HEALTH DEPARTMENT
Environmental Health Section PROPERTY INFORMATION
Permittee's P.O. Box 848
Name: Mocksville, NC 27028 Subdivision Name:
Phone # 336-751-8760
Directions to property: �i1, ri'✓," .��,J Section: Lot: S: le
AUTHORIZATION FOR s/ f
WASTEWATER
SYSTEM CONSTRUCTION Tax Office PIN:#J�.
---��
Road Name :''Y 17( (dA ip:
**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 applying for Building Permits.
(In compliance with Article I I 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 DATE ISSUED
DA
VIE C UNTY HEALTH DEPARTMENT
TMPROVEMENT AND OPERATION PERMITS PROPERTY INFORMATION
01
Permiftee's
Name- Subdivision Name -a' wA
2,
Directions to property: '-J: Section: Lot:
IMPROVEMENT
PERMIT Tax Office PIN:#,:5
Road Name:'�!4 t0tiTIJA 1p:
**NOTE** This Improvement Permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater system. An
AUTHORIZATTON 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 I I of G.S. Chapter 130A, Wastewater Systems, Section. 1900 Sewage T.reatment and Disposal Systems)
tM JrhKMJ1 I Z bUBJEU I I U KEVULA 11UN It b1l h
PLANS OR THE F14TENDED USE CHANGE. YOUR WASTEWATER
SYSTEM CONTRACTOR MUST SEE THIS PERMIT BEFORE
ENVIRONMENTA, L HEALTH SPECIALIST DATE ISSUED INSTALLING THE SYSTEM.
RESIDENTIAL SPECIFICA TION: BUILDING TYPE # BEDROOMS # BATHS :2 # OCCUPANTS - GARBAGE DISPOSAL: Yes or No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS — INDUSTRIAL WASTE: Yes or No
LOT PAIR SITE
SIZE TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD)--�W NEW SITE
SYSTEM SPECIFICATIONS: TANK SIZE 7 /ZZ-9GAL. PUMP TANK --GAL. TRENCH WIDTH,7;�P "' ROCK DEPTH I'INEAR Fr.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
IMPROVEMENT PERMIT LAYOUT
"CONTACT A REPRESENTATIVE OF THE DAVIE COUNTYPEALTH DEPARTMENT FOR FINAL INSPECTION OF THIS SYSTEM
BETWEEN 8:30 - 9:30 A.M. OR 1:00 - 1:30 P.M. ON )AE 7Y ��STALLATION. TELEPHONE # IS (336)751-8760.
OPERATION PERMIT
ALLED BY: -
/o 0 clte4lx
AUTHORIZATION NO. OPERATION PERMIT BY: 44�� DATE:
**THE ISSUANCE OF THIS OPERATION PERMIT SHALL INDICATE THAT THE SYSTEM DESCRIBED ABOVE HAS BEEN INSTALLED IN COMPLIANCE
WITH ARTICLE I I 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 WELL FUNCTION SATISFACTORILY FOR ANY GIVEN PERIOD OF TIME. i
DCHD 05/96 (Revised)
j APPLICATION FOR SITE EVALUATIONAMPROVEMENT PERMIT
Davie County Health Department U
Environmental Health Section
P. O. Box 848 JUN — 3 19UN
Mocksville, NC 27028
(704) 634-8760 ENVIRONh1ENTAL HEALTH
DAVIE COUNTY
****IMPORTANT**** THIS APPLICATION CANNOT BE PROCESSED UNLESS
ALL THE REQUIRED INFORMATION IS PROVIDED.
1. Name to be Billed o Contact Person K
Mailing Address W13
Uy VHome Phone � - -�- 7
City/State/Zip Coo lee mie A—Business Phone 414 - 255'
2. Name on Permit/ATC if Different than Above
Mailing Address
3. Application For:
4. System to Serve:
5. IfResidence:
®/ Dishwasher
City/State/Zip
❑ Site Evaluation [L' Improvement Permit & ATC ❑ Both
❑ House Mobile Home ❑ Business ❑ Industry ❑ Other
# People # Bedrooms # Bathrooms
❑ Garbage Disposal C" Washing Machine ❑ Basement/Plumbing ❑ Basement/No Plumbing
6. If Business/Other: Specify type
# Commodes
If Foodservice
7. Type of water supply:
# Showers
# Seats
M County/City
# People # Sinks
# Urinals
Estimated Water Usage (gallons per day)
❑ Well
# Water Coolers
8. Do you anticipate additions or expansions of the facility this system is intended to serve?
If yes, what type?
❑ Community
❑ Yes LW No
PROPERTY INFORMATION REQUIRED: *** IMPORTANT *** A PLAT OF THE PROPERTY MUST BE
SUBMITTED WITH THIS APPLICATION.
Property Dimensions:
1 WRITE DIRECTIONS (from
q
1 Mocksville) TO PROPERTY:
Tax Office PIN: #
Un C/4 C �
K-0(
1
1
Property Address: Road Name
City/Zip o
I I Or viI
Q
a�p�"
1
If in Subdivision provide information, as follows:
1
1
ir►�a-orf'
is
1
1
Name:
Lot #: / 0
1
Section:
1
1
This is to certify 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 application. I, hereby, give consent to
the Authorized Representative of the Davie County Health Department to enter upon above described property located in Davie County
and owned by� & �� to conduct all testing procedures
as necessary to determine the site suitability.
� � ' V
�
DATE / Q SIGNATURE
Revised DCHD (06-96)
L �.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
APPLICANT'S NAME ✓ ,1�
PROPOSED FACILITY
SUBDIVISION
Water Supply: On -Site Well
Community
Evaluation By: Auger Boring (, Pit
SECTIONS LOT,&
S. 1.2
DATE EVALUATED ,.2"W
PROPERTY SIZE
ROAD NAME
tom`
Public !�
Cut
FACTORS 1 2 3 4 5 6 7
Landscape position ,t
Sloe %
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure /
Mineralogy`(
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATION BY:
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscaae Position
R - Ridge S - Shoulder L - Linear slope FS - Foot slope N - Nose slope
CC - Concave slope CV - Convex slope T - Terrace FP - Flood plain H - Head slope
Texture
S - Sand LS - Loamy sand SL - Sandy loam L - Loam SI - Silt
SICL - Silty clay loam SIL - Silty loam CL - Clay loam SCL - Sandy clay loam
SC - Sandy clay SIC - Silty clay C - Clay
CONSISTENCE
Moist
VFR - Very friable FR - Friable FI - Firm VFI - Very firm EFI - Extremely firm
Wet
NS - Non sticky SS - Slightly sticky S - Sticky VS - Very Sticky
NP - Non plastic SP - Slightly plastic P - Plastic VP - Very plastic
Structure
SC - Single grain M - Massive CR - Crumb GR - Granular ABK - Angular blocky
SBK - Subangular blocky PL - Platy PR - Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD (01-90)
■
■
■■
■M
M
■■■■■■
■ESN■■
■■■■n
■■EM■■
■E■■E■
■M■■E■
■■EEE■
■EMME■
■ENNE■
■■NN■■
■E■N■■
■EN■■
■■NE■
■
■
■
■■■■EM■
■EMMEM■
■EMEME■
■O■M■■■
ONENESS
■E■■E■■
■■EM■■■
■EES■■■
■E■E■E■
■M■■E■■
■E■■EM■
■N■■■■■
■■E■■E■
■■EMME■
■■EMMM■
■E■■■M■
■■EME■■
■MEMME■
■E■ENN■
■MEMME■
MONSOON
■■EMM■■
■■MME■■
■E■M■M■
■M■■■M■
ONENESS
OMEN
MEN
OMEN
■■M■
MEMO
MEMO
■
■
■
■MMEMME■■■■
■M■■■M■■EM■
■EMEMOMM■M■
■EMMEMM■ME■
■EMEMMEMEM■
■EMM■■E■■M■
■MMEMMEM■M■
■EM■■M■■ME■
■EMEMOMM■M■
■EMM■MMEME■
■M■■M■■NE■■
■E■E■■M■■M■
■■MEME■EME■
■EMEMM■MEM■
■EM■■EM■■E■
O■
■■N■
■■E■
NONE
MEMO
■■E■
■EM■
MEMO
MEMO
ONES
SEEN
■■N■
■■M■
NOME
MEMO
NEON
■E■■
0
Davie County, NC' Tax Parcel Report Wednesday, January 4, 2017
Parcel Number:
NCPIN Number:
Account Number:
Listed Owner 1:
Mailing Address 1:
City:
State:
Zip Code:
Legal Description:
Assessed Acreage;
Deed Date:
Deed Book / Page:
Plat Book:
Plat Page:
Building Value:
WA"IA(i: T1I1J IN INUT A SUKVLI' Y
COOLEEMEE
Parcel Information
SOUTH DAVIE
M401 OA0010
Township:
Mocksville
5726910168
Municipality:
DAVIE COUNTY
82516538
Census Tract:
37059-801
SPILLMAN ROGER P
Voting Precinct:
SOUTH CALAHALN
PO BOX 738
Planning Jurisdiction:
Davie County
COOLEEMEE
Zoning Class: DAVIE COUNTY R-A,R-20
NC
Zoning Overlay:
DAVIE COUNTY CZOD
27014-0000
Voluntary Ag. District:
No
LOT 10 GRANT HEIGHTS 1.590 ac
Fire Response District:
COOLEEMEE
Land Value:
Total Assessed Value:
1.58 Elementary School Zone:
COOLEEMEE
12/2013 Middle School Zone:
SOUTH DAVIE
009450577 Soil Types:
GnB2
0006 Flood Zone:
158 Watershed Overlay:
DAVIE COUNTY
Outbuilding 8r Extra
Freatures Value:
Total Market Value:
9Amvs�li' I ! All data Is provided as is without warranty or guarantee of any Idnd 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 dalms or causes of action due to
SOU N S4 NC or arising out of the use or Inability to use the GIS data provided by this website.
�FCa
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENT PERMIT and OPERATION PERMIT
IMPROVEMENT PERMIT
Al
**NOTE** This improvement permit DOES NOT authorize the construction or installation of a septic tank system or any wastewater
system. AN 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 11 of G.S. Chapter 130A, Wastewater Systems, Section .1900 Sewage Treatment and Disposal Systems)
NAME GS` /" 'i- --'/J ✓�,sl��.�� PROPERTY ADDRESS r1!!i`��' I/}t /tLi-.' ' ' DATE
LOCATION '-f41il y.
SUBDIVISION NAME LOT NUMBER / SEC. /BLOCK NUMBER
RESIDENTAL SPECIFICATION: BUILDING TYPE , # BEDROOMS -T # BATHS t2 # OCCUPANTS GARBAGE DISPOSAL.: Yes/No
COMMERCIAL SPECIFICATION: FACILITY TYPE # PEOPLE # PEOPLE/SHIFT # SEATS INDUSTRIAL WASTE: Yes/No
LOT SIZE f""'` TYPE WATER SUPPLY DESIGN WASTEWATER FLOW (GPD) NEW SITE t/ REPAIR SITE
SYSTEM SPECIFICATIONS: TANK SIZE / L GAL. PUMP TAW GAL. TRENCH WIDTH _-^��T ROCK DEPTH 9` LINEAR FT.
OTHER
REQUIRED SITE MODIFICATIONS/CONDITIONS:
***THIS PERMIT IS SUBJECT TO REVOCATION IF SITE PLANS OR THE INTENDED USE CHANGE. YOUR WASTERWATER SYSTEM CONTRACTOR MUST
SEE THIS PERMIT BEFORE INSTALLING THE SYSTEM.
r
IMPROVEMENT PERMIT BY✓Cl/
**CONTACT A REPRESENTATIVE OF THE DAVIE COUNTY HEA�EPTMENT FOR FINAL INSPECTION OF THIS SYSTEM BETWEEN
8:30-9:30 A.M. OR 1:00-1:30 P.M. ON THE bkY OF I LAT . TELEPHONE # IS (704) 634-8760.
OPERATION PERMIT SI\M INS LLE D Y
T—
AUTHORIZATION N0. r OPERATION PERMIT BY111Y,10"� DATE
**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 136A, 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 10/95
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
7 V
P SAY 1 4 1993
1. Application/Permit Requested By
Mailing Address � o F)y 139 9 Home Phone -704 Z gel- "z 7q
��7n �Frl 1 :F /N C 7'?0I Business Phone "'1D�-:� -T
2. Name on Permit if Different than Above —BIZ 5
3. Application for: ❑ General Evaluation
4. System to Serve: ❑ House
Tank Installation Permit
Q" Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry t� ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision �� r-ZC�1' Section Lot #
No. of People
No. of Bedrooms
No. of Bathrooms
Dwelling Dimensions �,t n ` o
6. If business, industry, place of public assembly, other: Specify type /y
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Basement/Plumbing
❑ Basement/No Plumbing
❑ Washing Machine
❑ Dishwasher
❑ Garbage Disposal
7. Type of water supply: F'Public ❑ Private ❑ Community
8. Property Dimensions �OIo Sewage Disposal ContractorIr
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes O/No
If yes, what type?
'NOTE: Improvements Permits shall be valid from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
ttNC_lbr.l iG� �S, UCC��wlc
This is to certify that the information provided is correct to
incurred from this application. � /
DATE
PROPERT.0 INFORMATION KEQUIKEU:
Tax Office PIN: #-j'(1� Lci to ogapq
PROPERTY ADDRESS, as follows:
follows:
Road Name: JUIVM(w R(��(f
City: L,ri`c,w (4
SUBMIT A PLAT WITH THIS APPLICATION.
Revisions effective October 1, 1995.
of my knowledge, and I understWq I am responsible for all charges
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBE PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. t,�'/2. I DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representativ f t e Davie C my D a e t to a ter upon above described
property located in Davie County and owned by L
to conduct all testing procedures as necessary to detetmine saidsi�uitability for a ground absorption sewage treatment
and disposal system.
DATE 4
DCHD (1193)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME ' DATE EVALUATED
ADDRESS
PROPERTY SIZE
PROPOSED FACIILTY �WAIZ LOCATION OF SITEti
Water Supply: On -Site Well _ Community Public (/
Evaluation By: Auger Boring Pit _ / Cut
FACTORS
1 2 3 4
Landscape position
Slope %
HORIZON I DEPTH
Texture group
Consistence
Structure
MineralogY
HORIZON II DEPTH
j
Texture groupG
Consistence
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE
SITE CLASSIFICATION: EVALUATED BY: �A4 /
LONG-TERM ACCEPTANCE RATE: OTHER(S) PRESENT:
REMARKS:
LEGEND
Landscape Position
R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope
CC -Concave slope CV -Convex slope T -Terrace FP -Flood plain H -Head slope
Texture
S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt
SICL-Silty ;lay loam, SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR- V,. -y friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm
Wet
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic
Structure
,3C --Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water or inches from land surface to soil colors
with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
DCHD(01-901
■■■■.■■■■.■■■.M■■.■ENE■.N■■■■■■■.■■■■Ms■ ■EN■■■■■NO■■■O■■ ■■E■.■■
■■■■.■■■■■■■/■■■..■■■■■■■.■.■■■■ ■MEMO■■ ■■_■■■/■■■/■■■■■..■■■■/■
■■■■.■■■■■..■■■■■■■.■■■■.■.CNMe■NMN.■■■..■.■■/■_■■■__■■■■■■■■■.■■■
■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■ ■■■■ ■■■■■■■■■■■■■
■■■■■■■■■■■■■■■MEMO■/■■■■■■■■■■■/■■■■■■■■■.■/■ ■/■■■■H ■■■/.■■/■
■■■■.■■■■■.■■■.■■■■■■■■■■.■■■■■■■■■■■.■■�■■MC�MCNCMMMCCNEE■■■ ON
■■■■/■■■■■e■■■■■■■■M■■E■.e■M■■■■O■O■/■■■ ■■■ ■ ONE ■■ME■■n�■E
■■■■■..■.■■■■.■■■■■■■■■■■■.■■■■■■■N.N■N.N.eEN■■■■ ■■/■■■■■M■■■■■■■
■■■.■■■...■■■■■■■■■■■■■■■■■■■■■ ■■/■■.■N■/■MEMO■■/■■■■■■■■■■■■■
■■■■/■■■■.■■/■■.■■.■■..■/.N■■EEM/■■NC.u■EECN■EE/E ■■.■■_.■.■....�
■■eM■eM■■■■■■■■■■M■■M■MM/■■■■■■■■eC■■MEMEM M■n■/■MMC■M■■■C■■N■MC■
CC�CCCCCC�iiiiiC�CCCCC CCCC CiC�CCC CCiN'�'■CCi
MEN NEE
.................■MO.■N■■■OO■■■NOON/.NM■NE■...■. MEN M■NCMOMMOM
MEMO M■O■M■C
.■......■a....................................... ■
....■.............................../..■■■■.■■■■� im
■■MMn■EME■MM
CCC■':CCCCCC:CCCCCCCCCCCCCCCCCCC��CCCCCCCCCCCCCCC■C.CCCC■C'CMENNENC
':1'V::�CCHCCCCCCCCCCCCCCCC :::::CCCCCCCC'CMMa ■C■MMOMMEMN
O■MEM■
MEMO NN.............................■. .SOONER■ . ■M■C• ENMM■E■
........................■■MO■E■n■■■■■'■`'
OMEN ■ . ■■■�EMEM■■C
...................... ........'��' C' 'CCCCCI I
... EMEME
■■■M■■■OE■■■■■■■■■■■■EO■■■■N/E■■/■■ ■■ NO■-MMM=■ /.■■ �■ ■N■NENEEO■
MEMO■■■■■■ ■■■■■■ ■■.■■■ .NEEM ENN■ ■ ■ ■■. ■■■■■■
■.■■■MNON■■OOE■EO■■■■■■OE■CE/■■M■■ 0
NONE C ■O■■■O■■■
■■N■/■■■■■EE■O■■■MN■E■■■N■■■■■■■■■■/■ MN ■■ ■EN■ENO■
■■■■■■OO■■■.N■■O■OO■■O■O■ONO■.NOME■. M■ EMMEM■■.EOENo
■■
■■■■N■■ ■■■■■■u■■MMN■ ■■■/M■■■■ ■ MM ■NMN.
■■..■■■C■■NN■■■■■■■■C NN■■■ ■ ■ 'C.■CCNRON
■■■■■■■■■■■NNOu■NEN■�■■■C■■■ ■ ■■■■ ■■NCC■■■
■■■■■■■■■C■■■■u■H■■■■ ■■■ ■■■ ■■ ON MN■M■C■
■■■O■■M■O O■■■■OOH■OM ■■OCEC■NE M■ OEM M■ENE■MOOMMUM
C
■■■■N■■■■■■■■■■■OMM■M■O■E■■■MOON■ ■■ H■■■■■■
■■■■■■■■M■■■OMNO■■■■O■■N■OM■■MMM■ O■ ■ =■N■■■e
■■■NOOEEONNOCOE NOENOENN.OE■■EN■■■E■O■N■.E ■MMM■■E■MNE■NMM
■■CCCCNCC�CCCCC ■ uNONN■M■■EE NNMNH■
■■MECME ■MMMMMMMM■C■■■OIIMMC" CC'CCCCCEM■MM■ MMMM E:C■ NMMC .
MEMENMEMMI MOMMEMINEXIMME 0 0 M---MEM-M-M
■■■■■■■■■■■■■■■■■■O■.■E■NNNNOOO�A■ EMS MON
CCCCCCCCCCCCCCCCCuiiiiiiiC■�ii'■c�"■i=iC' ' iC""""'N""
■E.■.N. ■ ■■■.O■■E■■■■■■ ■■O■■■■■.■ ■ ■■. ■ ■ONE.E
CCCCCC ■ENOMONEE MMEMEMMEMOMMENMC MC '.: CC. CCCCCMOMMOMCCCCC
■■■■■ ■■CCE■O■■.■MC■OOO.■■ENOE .�■EN M■OO■OMCO■ONEONOONEMOON■NN
■......NOME■N■NMO■■■■■■■■OOE■OWN..........■MOON■■■■■■N■■■■■■M■
...........NNO■■NOO.E■■■.O■N.■.E■O■�■■NEE■NO.■O■■■O■■NE■■NON■
...................................... ..........................
..................................................................
.................................E■■EON■EM■VROOM■■N■EON.■O■■NE■■
........................... ......................................
...........................C■O■■NN■■■N.=........................_.
N■■■ ■■....N.■■■..■■■■■■■..■■.■�■■..■ ■■■■■■■■O■■■■■■■O■N■u■■ ■
Davie County Health Department
ENVIRONMENTAL HEALTH SECTION
P.O. Box 665
Mocksville, N.C. 27028
AUTHORIZATION FOR WASTEWATER SYSTEM CONSTRUCTION
(Issued in compliance with Article 11 of
G.S. Chapter 130A, Wastewater Systems)
***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 applying for Building Permits.***
AUTHORIZATION NLIVBER
NAME `� Z A v DATE
NAME ON IMPROVEMENT PERMIT (If different than
above)
SITE LOCATION
COMMENTS/CONDITIONS ON AUTHORIZATION TO CONSTRUCT WASTEWATER SYSTEM