273 Georgia Rd DAVIE COUNTY HEALTH DEPARTMEN
1� IMPROVEMENTS PERMIT AND CERTIFICATE OF,-COMPLETION
' *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Nam &L'-' `fir �:,?/i/� `: _ --5-896~?
Name,
�- ==N..
Location �� 'r �� u r G✓rl, �f r i ,-'—w . ! ' -- ;
Subdivision Name Lot No. Sec. or STock No,
Lot Size�� House Mobile Home _ , ---- Busir" ss "_ ` _ Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YESNO ❑ �Dd� ;� L '44
Auto Wash Machine YES LJ NO ❑ ��x�X��- ,.. � Y
Type Water Supply _
*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.
s
�c
Q
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 b
Aja
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.
r -
4 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
' Davie County Health Department 5
` Environmental Health Section Q►R 1
P. 0. Box 665
Mockoville, NC 27028 ��C+
1 . Application/Permit Requested By
Mailing Address f-/-- o,Y 'yl//
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: General Evaluation 2,"S/Tank Installation
5. System to Serve: 0 House 2-Mobile Home 0 Business
lL] Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People J Dwelling Dimensions X l
No. of Bedrooms J Basement/Plumbing
No. of Bathrooms . Basement/No Plumbing
9--Washing Machine !!d Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
S. Type of water supply: 0 Public Private 0 Community
9. Property Dimensions f.2�_3
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes . 9-40
If yes, what type?
+NOTE: Improvements Permits shall be valid for a period of -5
years from date issued. Improvements Permits are subject
to revocation, if site plane or the intended use change .
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from .this applicati
Date Signature
Dire-7-'.:.coni to Property .
,j 2e cv
o�e/lt Gr/ i wry zoiz
c�rav e ti
See 4-1 4elg-e Gv7l�%*-� 7`���s oma- C 7L
o/rI �,QecrL f70°Se />7 ,9/1,
-�hyf
DCHD..(10-89) .
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
s -
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 from , 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 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
/3-yaX 7a
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size ,F
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position QV S
PS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S Ste„
Loamy, Clayey, (note 2:1 Clay)
U U U
3) Soil Structure (12-36 in.) S
Clayey Soils & - - ® A�• S;
U U U
4) Soil Depth (inches) PS � (��-, S
?�
U U PU
5) Soil Drainage: Internal P
U U U
External ® S^ S
P
6) Restrictive Horizons
tel"
7) Available Space is is . SS S
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 `�'v��/ Title `� Date �<
SITE DIAGRAM
U'
Y � .
DCHD(6-82)
STATEMENT
5- DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. O. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE 03-22-90
Gary True
Rt. 8, 441
Mocksvill , SIC 27028
Site Eval. L Permit 5896 - $100.00
J
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
03-22-90 Site Eval. & Dermi.t 5896 Gar - True $100.00
0000
BALANCE DUE — $100.00
STATEMENT
• RAVIE COUM HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE 04-24-90
SECOND NOTICE
I Gary True
Rt. 8, Box 441
Mocksville, NC 27028
Site Eval. & Permit 5896 - $100.00
Billed 03-22-90
L J
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
03-22-90 Site Eval. & Permit 5896/Gary True $100.00
VA
BALANCE DUE — $100.00
. P
JOHN T. BROCK �0M
County Attorney for Davie County
P. 0. Box 347
Mocksville, NC 27028
May 31, 1990
Gary True
Rt. 8, Box 441
Mocksville, NC 27028
Re: Site Evaluation & Permit 5896
Billed 03-22-90
Dear Mr. True:
According to our records, you are in arrears in the amount of $100.00 on
your account with the Davie County Health Department for environmental health
services provided by our agency on your behalf. These fees were due and
payable at the time the service was provided and are now past due. Please
arrange to complete payment of the above amount within 10 days from the date of
this letter; otherwise, I will be compelled to take action to collect the .said
amount. Please send payment to the Davie County Health Department,
P. 0. Box 665, Mocksville, N.C. 27028.
Respectfully yours,
ohn T. Brock
County Attorney for Davie County
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