3720 Hwy 801SHEALTH DEPARTMENT RELEASE
Davie County Health Department
d �o 210 Hospital Street
P.O. Box 848
Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant: John and Dianne Lanier
Address: 3720 NC Hwy 801 South
City: Advance
StatefZip: NC 27006
Phone #: (336) 998-8657
PERMIT VALID 0 4/ 0 1/ a 0 2 0
UNTIL:
Property Owner: John and Dianne Lanier
Address: 3720 NC Hwy 801 South
City: Advance
State/Zip: NC 27006
111�hone #: (336) 998-8657
Property Location & Site Information
Address3720 NC Hwy 801 South Subdivision: Phase: Lot
Road # Advance NC 27006
SINGLE FAMILY Township:
*Strudure: Directions
# of Bedrooms: 3 # of People: hwy 64 east, left on Hwy 801 about 1 112 mile on left
*Water Supply: EXISTING WELL
Type of Business:
Basement: ❑ Yes R No
Total sq. Footage: No. Of Employees,
'Proposed Improvement:
Pole Cover for Van
Keep 5' minimum off septic.
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? QYes *No
Applicant/Legal Reps. Signature: "Date:
*Issued By: 2325- Mitchell, Brittany "Date of Issue:, 0 4 / 0 1 / 2 0 1 5
Authorized State Agent:
Site P Ian/Drawing attached."
a Hand Drawing OImportDrawing
Davie County Health Department
t836 r' - Environmental Health Section
P.O. Box 848.
. CESvE�210 Hospital Street
Courier #: 09-40-06
Mocksville, NG 27028
Date: -
Phone: (336) - 753 - 6780
ON-SITE WAS CERTIFICATION
(Check One) Replacement Remodeling Reconnection
Fax: (336) - 753-1680
Name: IOh/Lu�f�' �i� �`G� Phone Number '33c ome)
Mailing Address:% /VC p W / (Work)
& I Alt!- Z-10 0 a Email Address:
Detailed Directions To Site: X--�dVll KI /AIV-O/
V YQl d /v �t
Property Address: 277, 0 /VC W 06.5
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: c.l e)h ✓! �46K Type Of Facility:^&D rild a e
Date System Installed (Month/Date)Year): w g Number Of Bedrooms:__3 _Number Of People:
Is The Facility Currently Vacant? Yes 5 If Yes, For How Long?
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following Infor ation AboutTrIZO)Number
EW FacilityZl�x 3
Type Of Facility:T o C � �a 7 �myeiz, Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
Requested: .7- — I 1 — Us
Requested By:
For Environmental Health Office Use Only
6oD Disapproved
Comments: hu)5-R- Minimum F0 5;e j)+JCo
Environmental Health Specialist Date:_
*The signing of this form by the Environmental Health Staff is in ay 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 #: 2 �)f Invoice #:,
3720
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Printed -Nov 12, 2014
All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the 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 claims or causes of action due to or arising out of the use or
inability to use the GIS data provided by this website.
A
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-.196) Permit Number
Name —�CUA� !_,aAL•E Date 3615
Location i'r'e
3720 ., 11 WV d96 l 5, hito �vm
Subdivision Name Lot No. Sec. or Block No.
Lot Size -- Hpuse Mobile Home _� Business _— Speculation
No Bedrooms __ No Baths -- No in Famil
_ y
Garbage Disposal YES ❑ NO
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑
Type Water Supply
Specifications for System:
*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-61S.MAtj
Certificate of Completion------. Date
*The signing of this certificate shall indicate that the system describebove has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taKn 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 Date
Address Lot Size ,/ E
1:Ar.Tf1RR ARPA 1 AREA 9 AREA 3 AREA 4
) Topography/ Landscape Position
�)
3)
�)
6)
8)
9)
S
S
S
S
PS
PS
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
U
Soil Structure (12-36 in.)
S
S
S
Clayey Soils
P
PS
PS
PS
U
U
U
U
) Soil Depth (inches)
S
S
S
S
�3 j
PS
PS
PS
Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Restrictive Horizons
Available Space
S.
S
S
PS
PS
PS
U
U
U
Other (Specify)
S
S
S
S
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title Date
SITE DIAGRAM
DCHD (6-82)