P5322 Hickory St DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF'COMPLETION
*(COTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
ZSage.Treatmen and Disposal Rules (10 NCAC 10A .1934-.1968) . Permit Number
Name < mate
Location ��� ✓ :�i ,�f ��/. ��G ✓ ,C .�/ is _�`�
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 ❑ NO per' Specifications for Stem: �%
Auto Dish Washer YES NO 2 �" y
Auto Wash Machine YES NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
70
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Improvements permit by
l *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
3
C 1�
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Certificate of Completion Date h
*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 p ,
Environmental Health Section S�
P. O. Box 665 ; RS
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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Home Phone
1. Permit Requeste By �' ' e Business Phone
2. Address ZD / J o f Aq
3. Property Owner if Different than bove
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
Industry Other
b) Number of people
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms—Bath Rooms Den w/Closet .2
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 Sof water-using fixtures:
commodes urinals garbage disposal'
lavatory showers washing machine P
dishwasher /,p IkS7
8. a) Type water supply: Public Private Co unity
b) Has the water supply system been approved? Yes No 5e7Je
9. a) Property Dimensions 0 r P
b) Land area designated to building site
'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 th a bes of my knowledge.
Date O ner Signature
OWNER IS SOLgLY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
pjAllow 5 days for processing
Direction s to r e
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DCHD(6-82)
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. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
./ P Ze0Zq /17e e
(office use only)
Ts/
no 1. I am the owner of the above described property.
yes no 2. 1 am not the owner of the abpve described��cc��roperty, however, I certify that I
have consent from �► y e;-'o ' l , owner to obtain a
owner's name /
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 eV SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
— Owner only
— Owners designated representative
Anyone requesting results
— Only those listed below
4'
DATE V SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
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
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
g
PS PS PS
U U U U
5) Soil Drainage: Internal S S S
PS PS PS PS
U U U .
External S S S
pS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �� Title `' Date
SITE DIAGRAM
A ,
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DCHD(6.82)
Davie County Nealtl DD5 artment
and Aome Nealtl yency
210 HOSPITAL STREET/P.O.BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634.5985
November 2, 1988
Mr. Rick McCrary
P. 0. Box 1019
Cooleemee, NC 27014
Re: Site Evaluation
Dear Mr. McCrary:
On September 16, 1988, this office evaluated a lot on Hickory Street in
Cooleemee to determine if it was suitable for the installation of a septic tank
system. On that date it was classified provisionally suitable.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosures
cc: Jesse Boyce