130 Feed Mill Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION , �—�-
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`NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name Date J N23
Location ;'• ,� i ,f i k,
t�,'
Subdivision Name Lot No. Sec. or Block No.
Lot Size o " House Mobile Home — Business Speculation
No. Bedrooms T- No. Baths `` No. in Family--
Garbage
amily _.Garbage Disposal YES ❑ NO EY Specifications for System:
Auto Dish Washer YES ❑ NO [�'
Auto Wash Machine YES ❑ NO ❑r f ` - .L, '''
Type Water Supply __—
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*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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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 '
Certificate of Completion cr` ~`�` Date � 4 'l �t
*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.
=� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
�9
Environmental Health Section RECEIVE
F E B 1
P. O. Box 665 RE
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By - u �J��' V �' /Z Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install 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
.-7 Industry Other
b) Number of people J
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
3'
7. Number and type of water-using fixtures:
commodes ? urinals y garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public '� Private Community
b) Has the water supply system been approved? Yes t�fNo
9. a) Property Dimensions 512 �( 2-
b)
b) Land area designated to building site "�e �`'
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c) Sewage Disposal Contractor
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 the est of'my knowledge.
�J/�r
Date Owner SignalCure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
1 Allow 5 days for processing
Directions to property:
4
DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
L ATIQN_ F oRO E TY DATE RECEIVED
VL qll— (office use only)
yes no 1. I am the owner of the above described property.
yes no 2. 1 am not the owner of the above described property, however, I certify that I
have consent frorr � � ,,.–=:w9/i .kI/2 - owner to obtain a
owner's name t/,,,,-cc
site evaluation by the Davie County Health Department for the purpose of
determining the suitability for a ground absorption sewage treatment and
disposal system.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
wner only
— Owners designated representative
Anyone requesting results
— Only those listed below
C11--
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DATE
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION _ -- '6
Namey r'. V" y Date
Address Lot Size
FACTORSREA 1 A EA 2 A EA 3 AR 4
1) Topography/Landscape Position S S
PS
U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) d5s PS
U UU
3) Soil Structure (12-36 in.) S
Clayey Soils PS PS
U U =-U U
4) Soil Depth (inches) S S
4 PS PS
U U U
5) Soil Drainage: Internal S S S
P d�t> PS PS
U U
External S S S
PS PS � tPS)
U U U U
6) Restrictive Horizons
7) Available Space
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U ,\U C
9) Site Classification ::=� (S� V J . (2S
U—UNSUITABLE S—SUITABLE (,%.S—Provisionally�SSuitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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Davie County Aealtli De artment
and .dome Nealt§ Myency
210 HOSPITAL STREET I P.O.BOX 665
MOCKSVILLE.N.C. 27028
PHONE'S(704)634-5985
February 15, 1989
Advance Memorial Post 8719 V.F.W.
Attn: Taylor Howard, Post Commander
P. 0. Box 73
Advance, NC 27006
Re: Site Evaluation
Old Mill Road
Dear Mr. Howard:
On February 14, 1989, as you requested a representative from this
office visited the above mentioned site. The soil was found provisionally
suitable for the installation of a ground absorption sewage system. The
system will go in the front portion of the lot. The number of people must
be known before the system can be designed.
If you have any questions, please feel free to contact this office.
Sincerely,
Charles E. Little, R.S.
Environmental Health Section
CL/wd
Enclosure