4140 Hwy 801SHEALTH DEPARTMENT RELEASE For office use only
;CDP File Number 196699-1
Davie County Health Department
18-000-000=1103
" 210 Hospital Street County ID Number.
P.O. Box 848.
Evaluated For HDR/WWC
Mocksville NO 27028'
Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VALID 0 9 1 7 / a _ 0__ 2 0
UNTIL:
Applicant: Buffy Longworth
Address: 4140 NC Hwy 801 South
City: Advance
State0p: NC 27006
Phone #: (336) 466-1381 _
("Property Owner. Buffy Longworth
Address: 4140 NC Hwy 801 South
City: Advance
State0p NC 27006
Phone #: (336) 46671,381
Property Location & Site Information
rAddress4140 NC Hwy 801 S Subdivision:
onart!t ea.,ti.,.b wM` _ _ 77AAR
'Structure: SINGLE FAMILY
# of Bedrooms: 3 # of People: 3.
'Water Supply: PUBLIC
Basement: [] Yes ❑ No
'Proposed Improvement:
Modular Home
Phase: Lot:
Township:
Directions
Hwy 64 East left on Hwy 801 beside 1 st brick home on left.
Type of Business:
Total sq. Footage: No. Of Employees:
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:
*Issued By: 2140 -Nations, Robert *Date of Issue: 0 9 1 1 7 2 0 1 5
Authorized State Age
"Site Plan/Drawing attached.**
@Hand Drawing OImportDrawing
HEALTH DEPARTMENT RELEASE 196699-1
d0 3, Davie County Health Department CDP File Number:
210 Hospital Street J8-000-000-1103
_ P.O. Box Bas County File Number.
Mocksville NC 27028 Date: 09 / 1 _7 / 2, 0 1 5
Qlnch
Scale: QBlock
Drawing Type: Health Department Release QiV/A
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Davie County Health Department
AID
�.;g Environmental Health Section'.
Date:
r. P.O. Box 848'
C�
210 Hospital Street
Courier # : 09-40-06 n.
Mocksville, NC 27028
Phone: (336) - 753 - 6780 Fax: (336) - 753-1680
ON -S ATER CERTIFICATION
(Check One(jWLcemeuO Remodeling Reconnection
Name: Phone Number 33 h — (Home)
Mailing Address:,uY_i%% -S I I (//Work)
!t� ' Email Address:
Detailed Directions To Site: H w1i 90 1 S
'E. n mi #wu x i ko� oN 0 baidi iso
Property Address: i�ao C �i Z2 0 0 -000 ' 033
Please Fill In The Following Information About The EXISTING Facility: n
Name System Installed Under: JL40-1J/je_ Tcl TTS Type Of Facility:_
Date System Installed (Month/Date/Year):q y Number Of Bedrooms -s3 Number Of People:
Is The Facility Currently Vacant? Yes No If Yes, For How Long? 4j��As /11 Otte S ct,n ► 9; cX
Any Known Problems? Yes No If Yes, Explain:
Please Fill In The Following
,t Information About The NEW Facility:
Type Of Facility: Ih 1Z_ Number Of Bedrooms: _Number of People
Pool Size:
Requested By:
Garage Size: Other;
Requested:
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist Date:
*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
Payment: Cash
Money Order #
Amount:$
Paid By: Received By:
Account # �7 (d ISD Invoice #:�%
Date:
spot
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DAVIE COUNTY HEALTH DEPARTMENT
w �' +y• IMPROVEMENTS PERMIT AND CERTIFICATE . OF COMPLETION t• I ,
"NOTE: Issued in Compliance With Article 11 of G,S. Chapter 130a 2 v�
~~`CSanitary Sewage Systems _
Name
�\�2 o _ Date
`
Location - �� �- $ , A v Esc+ c a N �°•
Permit Number
N27508
Uv% '
BQtS
Subdivision Name Lot No. Sec. or Block No.
Lot Sized House Mobile Home Business -- Industry
No. Bedrooms No. Baths _� No. in Family _ Public Assembly Other
Garbage Disposal YES C3/ NO Q S ecifications'for System:
Auto Dish Washer: YES e NO Q �Ov.o,
Auto Wash Ma^.hine YES rr' NO
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 revocati n if'site plans or the intended use change.
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Improvements permit byC�
*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: 704634-5985.
Final Installation Diagram:
System Installed by _ � `� i• ��.4
`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
Soil/Site Evaluation
NAME -- riU G 'Ao o S
ADDRESS
PROPOSED FACIILTY
DATE EVALUATED
PROPERTY SIZE
LOCATION OF SITE
Water Supply: On -Site Well Community Public
Evaluation By: '� 1 Auger Boring Pit Cut
FACTORS
1
2
3
4
Landscape position
S
5...
Sloe %
HORIZON I DEPTH
2"
12
_5'
Texture group
L
Q, L
Consistence
F T
Structure
I P
C,
Mineralogy
1"I
1'• 1
HORIZON II DEPTH
6
3
Co
Texture group
Consistence
`Z
IF
-
1
Structure
Mineralogy
HORIZON III DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
3
SS
RESTRICTIVE HORIZON�—
SAPROLITE
--
�-
CLASSIFICATION
Y,S
Q
LONG-TERM ACCEPTANCE RATEI
Lj
L1
4
w
SITE CLASSIFICATION: 5'
LONG-TERM ACCEPTANCE RATE: L\
REMARKS: \%
DCHD(01-901
EVALUATED BY:
OTHER(S) PRESENT:
Landscape Position
R -Ridge S -Shoulder L -Linear slope FS -Foot slope N -Nose slope
CC -Concave slope CV -Convex slope T -Terrace FP -Flood plain H -Head slope
Texture
S -Sand LS -Loamy sand SL -Sandy loam L -Loam SI -Silt
SICL-Silty flay loam SIL -Silty loam CL -Clay loam SCL-Sandy clay loam
SC -Sandy clay SIC -Silty clay C -Clay
CONSISTENCE
Moist
VFR-Very friable FR -Friable FI -Firm VFI-Very firm EFI-Extremely firm
Wet
NS -Non sticky SS -Slightly sticky S -Sticky VS -Very Sticky
NP -Non plastic SP -Slightly plastic P -Plastic VP -Very plastic
Structure
3C -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineralogy
1:1, 2:1, Mixed
Notes
Horizon depth - In inches
Depth of fill - In inches
Restrictive horizon - Thickness and inches from land surface
Saprolite - S(suitable), U(unsuitable)
Soil wetness - Inches from land surface to free water` or inches from land surface to soil colors
with chroma 2 or less
Classification - S(suitable), PS(provisionally suitable), U(unsuitable)
LTAR - Long-term acceptance rate - gal/day/ft2
■m■■
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-�� APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS PERMIT
: 2 Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028 MAR 3 0 1994
N-e.A Q 0— - J PS lC' I --------------- i
1. Application/Permit Requested By I
MailingAddresa-L a � 4n� �- Home Phone `1n 1 Q-qqr�-a6'(-,9
o 0 0 Business Phoneg��'�`1� " SQ
2. Name on Permit if Different than Above — LUQ I l 12 rr� , +�S
3. Application for:
4. System to Serve:
❑ Business
❑ General Evaluation Septic Tank Installation Permit
❑ House 1pl%obile Home
❑ Industry ❑ Other
5. If house, mobile home: Subdivision
No. of People
No. of Bedrooms 3
No. of Bathrooms
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type _
No. of People Served
No. of Commodes _
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: ❑ Public ❑ Private
8. Property Dimensions A 6LC'1� Sewage Disposal Contractor
❑ Place of Public Assembly
❑ Unknown
Section Lot #
❑ Basement/Plumbing
❑ Basement/No Plumbing
5a,fMashing Machine
C 11%hwasher
G]-19arbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 5/No
If yes, what type?
Community
'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: fr0m KI o e 4 v. I- -,o,(c A Lt q- easy a t[ Vim" w4-6
-K-t- Gra SS ro cd sk4LJ& I (e q t--I-i,� l -h I -e_-%(- 1 N C4iwnrds Lz4i3-,amu)
Lrwk t k ak `-I�-t -�i rs 4-au,Q.c ov, JrCk I -1- Ywaa WiL4Zkcfc 'hau-e c CA, 4li (1�
KA3 -[-u h -C b -C h t wd -V-'(- bcLr r\ -e- e
LNY
Y, r cslk--( u s � eLr e C.om i w� � `l CC c_ r D u e. w a� . ( � w �'t f % e VA4 r LQ -4)
L 2 re i S 0. w t4--yrvw` w� u la -e !� ►L n lit a
�a ►-n . Cw r � t r nom. are -I-.e [-e p %t
m mrA 1, h 4J
This is to certify that the information provided is correct to the best of my knowledge, and I unde I am responsible for all c rges
incurred from this application.
_3 :-,3 a - 4 �9
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 1. I OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or, a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (1/93)
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS 'PERMIT AND CERTIFICATE OF COMPLETION I
.* NO 7 E: issued in Compliance With Article 11 of G.S. Chapter 130a
x —`Sanitary Sewage Systems Permit Number
Name —AIA) '` `{ re s Date - N0 7 5 0 8
Location g' P v F• t• N e. '� u v
SL2- 446ft l!– J I J q/ 9015
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home V Business --- Industry
No. Bedrooms 3 No. Baths 2 No. in Family _ Public Assembly Other
Garbage Disposal YES E3/ NO ❑ Secifications for System:
Auto Dish Washer YES d NO ❑
Auto Wash Ma:hine YES [g� NO ❑
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 revocati n if site fplans or the intended use change.
\ 'u
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714A\A\
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 _I.j��"�►,���
FA
C,
t
Certificate of Completion' v Date U -
*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.