143 Jamestowne Dr ..•aid, '4 r �!` �.i,.3 :�� : wlr. 1„ .+:•,al H' S;1 . � s.6�'� f !,_ t,.
77,
DAVI COUNTY HEALTH DEPARTMENT
r' IMPROVEMENTSPERMIT AND .CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
- Sa" ita e
ry Sewas Systems " - �'/ - �rr�. Permit Number
Name a� l�r-- �el.�r'Ar �� n / 1�. NO
6540
Location �" q tr rz2Z .11ZJ ,01- ��'
Subdivision Name Lot No. Sec. or Block No.
Lot Size f Z)6 House Mobile Home —L%` Business Speculation
No. Bedrooms No. Baths— ? No. in Family�2
Garbage Disposal YES p NO p, Specifications for System:
Auto Dish Washer YES [ NO p ���
Auto Wash Ma thine YES Ep NO p '/'`
Type Water Supply �E,
*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.
`J
11 ,
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 WZ�
/Ob
Certificate of Completion i'� 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.
-, ,
. ~ • fly. ,,, � �/�a/�9
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
,S �+ Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT B GIN UNTIL IMPROV S PERMIT HAS BEEN ISSUED.
ic)
VqA 2a
Home Phone-
1. Permit Requ ted By Business Phone
2. Address 3-'a
3. Property Owner if Different an Above
Address
4. Permit To: a) Install .1/ Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House !!fMobile Home Business
Industry Other
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 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)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher _�� sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? YeI No
9. a) Property Dimensions
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? Aj O
What type?
This is to certify that the information is correct to the best of my kn wledge.
Date O ner Signature -S
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
10
Q
DCHD(6-82)
' Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
I � 13 � (office use only)
yes no 1. I am the owner of the above described property.
es no 2. 1 am not the owner f the bove described p pe y, however, I certify that I
have consent fromo
�-� C- , 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.
D- -�g - - �.
DATE SIGNATURE 6 6
4. 1 hereby authorize the Davie County Health Department to release site
evaluation resu from the above described property to the following:
Oyy�vner only
'Owners designated representative
Anyone requesting results
— Only those listed below
p•�--J
DATE SIGNATUREV
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
� SOIL/SITE EVALUATION
Name 1-1,d 17 5 –" Vie! lyew ,c' 17' Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S
PS (P9 PS PS
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) (!! b
U U U
3) Soil Structure (12-36 in.) ------------ S
Clayey Soils �(
U l7
4) Soil Depth (inches) (SS
U
T1' P
5) Soil Drainage: Internal S(9�
U U U U
External (b "IF
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Spaced
PS S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification -Jl /
C–
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: //Q
Described by Z Z Title �C ,� Date
SITE DIAGRAM
DCHD(6-82)
Davre County Nealtlf Deparhnent
and .dome Nealtl Ayency
210 HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634-5985
October 16, 1989
Andrew Holt
c/o Betty Potts Realty
Rt. 3, Box 320
Mocksville, NC 27028
Re: Site Evaluation
State Road 1713
Dear Mr. Holt:
On October 16, 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.
If. you have any questions, please feel free to contact this office.
Sincerely,
Pr
Robert B. Hall, Jr. , K.S.
Environmental Health Section
RH/wd
Enclosure