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493 Bailey Rd HEALTH DEPARTMENT RELEASE For Office UseOnly *CDP FIIe Number 191283-1 Davie County Health Department r 210 Hospital Street County ID Number: P.O.Box 848 HDR/WWC • Evaluated For: Mocksville NC 27628 Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 3 / 1 3 / a 0 a 0 UNTIL: Applicant: Joseph and Anne Aloi Property Owner: Joseph and Anne Aloi Address: 493 Bailey Rd Address: 493 Bailey Rd City: Advance City: Advance State2ip: NC 27006 State2ip: NC 27006 Phone#: Phone#: Property Location&site Information Cddress493 Bailey Road Subdivision: Phase: Lot:oad# Advance, NC 27006 SINGLE FAMILY Township: tructure: Directions #of Bedrooms 4 #of People: 1-40,exit Hwy 801,go south,cross railroad tracks,left on Fre Station Rd.left at stop sign,right on Bailey Rd.Near the end on left 'Water Supply: N/A Basement: [:]Yes F]No Type of Business: Total sq. Footage: No.Of Employees: 'Proposed Improvement: REmodel Existing Barn,wash stall,sink,WM .Rolease Conditions i e"41Pa bf-oDk iNsoon4fL4(0V' n 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-, *Date: / * 2140-Nations,Robert Issued By: Date of Issue: 0 3 1 3 x 0 1 5 Authorized State Agent: **Site Plan/Drawing attached.** `{; , Q'Hand Drawing Olmport Drawing Davie County Health Department 4 X18 f Environmental Health Section P.O. Box 848 a 0 ,�,a;� ��'�V�i+� 210 Hospital Street Courier# :09-40-06 Mocksville, NC 27028 Phone:(336)-753-6780 Fax:(336)-753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: Joseph and Anne Aloi Phone Number ij`' 4� W N t'L<<' (Home) Mailing Address: 493 Bailey Rd, ZTf' 0-orlo (Work) Advance,NC Detailed Directions To Site: Property Address: 493 Bailey Rd,Advance,NC Please Fill In The Following Information About The EXISTING Facility: Name System Installed Under: John and Cindy Halverson Type Of Facility: Pole Barn/Horse Barn Date System Installed(Montt/Date/Year): approx.2009 Number Of Bedrooms: N/A Number Of People: N/A Is The Facility Currently Vacant? Yes No If Yes,For How Long9 No-Horses Any Known Problems? Yes No If Yes,Explain: No Please Fill In The Following Information A out The NEW Facility: gtN k/ �!1/�1'S}f)�tQ�E I/�l�, loor v24;rJ Type Of Facility: Remodel of Existing Pole Barn 4 Wjbil 5fA�_Number Of Bedrooms: O Number of People 0 Pool Size: Garage Size: Other: X Requested By ate Requested: 02/12/2015 (Si a e) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist 566 0 N Date: 13 15 *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: Cash Check Money Order # Amount:$ Date: Paid By: Received By: Account#:-I �_ �j Invoice#: SEEM MONSIMMI Mi M ME 0 MEMO Mi No uS M SMEMSEM MOMME mom 0MONSIM EMSEM M OEM =MEN NONE MOMMEM MR 0NEMMEM MOMME 0 ON ■ Sol M r., ME I ME NOON NO No Effim., IT.2 Frei] .01 SM ONEMOM MME M ME MOM MENSMOM ON No ON - I no MEN NONE INEMONSEEME M 10 INEMp No M EMEMOSEEMOSEM M ME M M■ a MEN 0 0 NONE MEMMEM M NJ air. No R M No M M M M No M in MEN INS M on MEN ME ON INN ON a 0 ROME 0 No is no OEM MINN I mm ON NMEMEM �u of 40 C- DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION •NOTE:Issued in Compliance With Article 11 of G.S.Chapter 1 0a Sanitary Se age§ystems Permit Number Name . � / " • � ate/D-6-9Y N21752 Location , /Maa Subdivision Name Lot No. Sec.or Block No. Lot Size2/— ��// House Mobile Home— Business'--Industry 'n a No.Bedrooms_L._.No.Baths No. in Family Public Assembly Other V Garbage Disposal YES NO ❑ Specifications for System: to Auto Dish Washer YES NO ❑ �� Auto Wash Ma^hine YES NO ❑ �O�k.S .f'/0Z Type Water Supply 'This permit Void if sewage system described below is not installed within 5 years from W-0--fLssue. This permit is subject to revocation if site plans or the intended use change. 1 r Improvements permit by *Contact a representative of the Davie County Health Department for final Inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number.704-634-5985. Final Installation Diagram: System Installed by J ifd Certificate of Completion Date /0 6�Y 'The si ing of this at shall indicate that the system described above has been installed in compliance with the standards�se r above regulation,but shall in NO way be taken as a guarantee that the system will function • 'DAVIE COUNTY HEALTH DEPARTMENT _ --- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION Issued in Compliance with G.S.of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1,x68) - Permit Number Name 'ice=y� �"L . Date �', yY" Location "7,��,.✓'! �~:� :'f,�f� ,�.-�- �l� �'/ �.', �, ;� b - Subdivision Name Lot No. Sec.or Block No. Lot Size ;'" House —Mobile Home_ Business Speculation _ --No. Bedrooms No. Baths No. In Family _ Garbage Disposal YES 0 NO 0— Specificationsfor System: Auto Dish Washer YES p NO 0 ' Auto Wash Machine YES NO 0 Type Water Supply 'This permit Void if sewage system described below is not installed within 36 months from date of issue. Improvements permit by '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 � ,!' •') lN, ' ,tr„v Certificate of Completion Date-h � 1 '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 taken as a guarantee that the system will function satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT = IMPROVEMENTS PERMIT AND. "CERTIFICATE OF COMPLETION F *NOfE:Issued in Compliance.With Article II of G.S.Chapter Wa Sanitary Sewage Systems Permit Number n: "Name " �F a,� . / _ ate /r%'-� 9y N° 7752 Location _ J Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business, Industry No. Bedrooms No. Baths �' No. in Family �� Public Assembly Other Garbage Disposal YES NO ❑ Specifications for System: Auto Dish Washer YES NO ❑ Auto Wash Ma thine YES NO ❑ gook iia Type Water Supply — ,-vim— �-= ---- 'This permit Void if sewage system de ibe )1-low is not installed within 5 years from of gq This permit is subject to revocation ii site pl�fis or the intended use change. 1� fl Improvements permit by -- � 'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by p Certificate of Completion Date 'The signing of thisI at shall indicate that the system described above has been installed in compliance with the standards et or in th above regulation, but shall in NO way betaken as a guarantee that the system will function satisfactorily, iv period of time. r. ^a<� + {1'3 ti�i-` + i«w"5'ui:f'i+' -:+y=,:-ice i°.'w:ry>Tt >`r Tw,:r >w �i:ir•v,•r-`r.yM i.-'-- t,;r:..,,r _:}, � ?. t _. _ .. �. r.w • • ' • �CO G DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ejo; •NOTE:Issued in Compliance With Article I I of G.S.Chapter 1 0a . Sanitary Sewage�ystems ,/ Permit Number Name f/'� . ./ . 4ate /D-6o N- 7752 Location 1. Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _T Business Industry No. Bedrooms .No. Baths No-in Family 677 Public Assembly Other Garbage Disposal YES NO ❑ Specifications for System: Auto Dish Washer YES NO ❑ �� Auto Wash Ma:hive YES NO ❑ ©Qk� ��a Type Water SupplyT *This permit Void if sewage system described below is not installed within 5 years from of This permit is subject to revocation if site plans or the intended use change. ---�^" p / Oo c Improvements permit by _6a `Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M. or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by F po Certificate of Completion Date �6-6 'The signing of this at shall indicate that the system described above has been installed in compliance with the standards or in t above regulation, but shall in NO way be taken as a guarantee that the system will function satisfactorily for period of time. Gr • "+ 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) Permit Number Name tl� .t%°, �" - Date , - j 3 Location ��, � i✓E �✓ , - ;i,T c !- „%�i —//`�. Subdivision Name Lot No. Sec. or Block No. Lot Size f'/ House Z--" Mobile Home _ Business Speculation No. Bedrooms — No. Baths No. in Family—:!,-:Z— Garbage Disposal YES ❑ NO Specifications for System: Auto Dish Washer YES NO ❑ /�� `�; ` Auto Wash Machine YES [� NO ❑ J Type Water Supply i 1. --- yGl�,1 r,{'/:�•r ,�J �� "This permit Void if sewage system described below is not installed within 36 months from date of issue. V Improvements permit by �� "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 1 7 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 taken 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 r Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S r PS PS PS U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS�f5 U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS U U U U 4) Soil Depth (inches) S S S P PS PS PS U U U U 5) Soil Drainage: Internal S S S S PS PS PS U U U U External S S S PS PS PS U > U U U 6) Restrictive Horizons 7) Available Space S S. S S PS PS PS <::75 U U U 8) Other (Specify) S S S S �R9 PS PS PS U U U U 9) Site Classification U—UNSUITABLE S—SUITABLE —Provisionally Suita Recommendations/Comments: Described by Title Dateh SITE DIAGRAM DCHD(6-82) whX \ ` LIGATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT L,2ell Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. t Home Phone �— n 1. Permit Requested By Business Ph ne D 2. Address G AA p/ 3. Property Owner if Different than Above U L Address ` �- 4. Permit To: a) Install f,/'Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home Business IndustryOther b) Number of people— :�4 6. a) If house or mobile home, state size of home and number of rooms. House Dimensio �- Bed Rooms Bath Rooms_ Den w/4Wel`� b) If Business, Industry or Other, State: Number of persons served What type business, etc. JA__ Estimate amount of waste daily (24 hours) N t gavatmoiry d type of w er-using fixture odes urinals garbage disposal l showers washing machine swasher sinks 8. a) Type water supply: Public Private C munity b) Has the water supply system been approved? Yes No _ 9. a) Property Dimensions '� V-e b) Land area designated to building site _ c) Sewage Disposal Contractor I/ 0-6 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to a best of my knowledge. t Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AN LOCAL LAWS Allow 5 days for processing Directions to property: Z' paa'-v 3 �� - go s DCHD(6.82)