4464 Hwy 801N -". DAVIE COUNTY HEALTH DEPARTMENTgot
- yr IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE: Is$ped in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit_Number
Nome , ,' ,�, Date z - u;" ;. 4126
Location hok t.N i' Viaat .. c . . �� �ti:. .,f Ch,:,:
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home_ Business Speculation
No. Bedrooms No. Baths t No. in Family j —
Garbage Disposal YES ❑ NO p Specifications for System: k n- N -0.
Auto Dish Washer YES ❑ NO p'
Auto Wash Machine YES p- NO ❑ ,, �. _ u x ,- �„`�
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by(:_ , .'S "N S
`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: l Ste InVed by
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Certificate of Completion Date l�
'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.
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It is agreed between the Pastor and Trustees
of The Chinquapin Grove Baptist Church to
allow Willa Van Eaton Cummings to install a
sewer system on the property of the church
as per Health Department requirements .
Any repairs needed to system will be the
responsibility of Willa Van Eaton Cummings .
DATE:.
SIGNED:'
PASTOR:
TRUSTEES:
1
Pavie fgaun#U Peal#h Pepar#men#
• nub game pettl#li '�genru
P. O. BOX 665
fflochsirille, North Carolinu 27028
OFFICE OF THE DIRECTOR TELEPHONE
September 30, 1985 17041 634-5985
Willa Van Eaton Cummings
2259 Creston Avenue
Bronx, New York 10453
RE: Soil/Site Evalation of Chinquapin
Baptist Church Property
Ms. Van Eaton Cummings:
As per your request, the aforementioned property was evaluated by this
office on September 23, 1985. The purpose of said evaluation was to deter-
mine the soil/site suitability for the installation of a ground absorption
sewage system to serve the mobile home located on your property. Enclosed
please find a copy of the evaluation. The area we evaluated has been classified
as provisionally suitable. Thus an oversized system could be installed at a
shallow depth. Also enclosed please find a very rough sketch of the area we
will have to'have available to us for the system to be installed. The area
that has been shaded in is the area where the system will have to be in-
stalled with repair area available.
Before this office can issue the necessary permit, we must have on
file in our office, the signed easement from the church allowing your sewage
system lines to be installed on their property. As soon as this easement
is on file we shall proceed with the permiting procedure.
Please advise should this office be of further assistance concerning
this matter.
S' cerely,
an , s,
e Mando, R.S.
Environmental Health Coordinator
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Enc.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �►-�'•>> 0. `1 a.. Fa��. Cavh.r.;n�s
Date
Address Lot Size C�,ura- p„• �.���
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ® PS PS clm:>
U zg�> U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils (n!�!> PS PS Zff8b
U QUI- U= U
4) Soil Depth (inches) S S S S
� n P$ PS PS Z�► PS
U c3j'-) U
5) Soil Drainage: Internal S S S S
External S S S S
<!:�
U U U U
6) Restrictive Horizons �, �o-,Zt•
2,U SAP' � �1« -D• lr,o►��`j ZQ SPP'
7) Available Space S S. S S
PS PS PS PS
U 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: S �cw sin a'� Z er4'
Described by Title �l`0'` Date �- 2 3-8 s-
,SITE DIAGRAM
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DGHD(6-82)
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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. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only_
is Al- e 4,2. R _ (� .v
If
yes no 1. 1 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 IGNA
4. 1 hereby authorize the Davie County H Department to release site
evaluation results from the above describe property to the following:
Owner only
Owners designated representative
Anyone requesting results
Only those listed below
DATE SIGNATURE
DCHD(11/84)
_ _ e
• 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: -filly j �' DATE RECEIVED
. (office use onl )
yes no 1. 1 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 ,` •���d
—Anyone requesting results
— Only those listed below
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i� AC
DAT ! Z' IT;
UY E
DCHD(11/84) /
It is agreed between `the Pastor and Trustees
of The Chinquapin Grove Baptist Church to
allow Willa Van Eaton Cummings to install a
sewer, system on the property of the church
as per Health Department requirements .
Any repairs deeded to system will be the
responsibility of Willa Van Eaton Cummings .
DATE:
SIGNED:
PASTOR: � � l ► .
TRUSTEES.:
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date / 7
AddressZ l'r�sT�' Aoc�i.� Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4 .�
1) Topography/Landscape Position S S S S
PS PS PS PS Ps Ps
U e-M
2) Soil Texture (12-36 in.) Sandy, S S S S ,
Loamy, Clayey, (note 2:1 Clay) 2,.i PS PS t � Z l ! Z'./ � N�'�
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
4) Soil Depth (inches) S S S S
PS PS PS PS
u-
5) Soil Drainage: Internal S S S S
PS PS PS PS
External ® ® ® �s �s
U U U U
6) Restrictive Horizons 8'��.� tlo"j
c
7) Available Space S
� ® <T'D �J
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification //J—'fi
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommend ations/Comments: I o+- wn� ahp- 4 4- H 2O l:k - :6e-F-"-"- All a f�c-c-
C 6— Aaick rnS "o,_ eel- sl Q r-ta , Fin ti..l F:I I O cj— L-'L-W".0 0-1(- d. �`ch.....�.�� o.�.,:._d�••:t��,
Described by Ma---O- uMAA,- Title Date 9-17"'�5;4
SITE DIAGRAM '{ 'I
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Church
DCHD(6-82) � 8fl
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �t.l
davie County'HealW Department ,p,'
Env!ronmental:Health�Section J11f
P. O. Box 665
• Mocksville, N.C. 27028: - �q
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PER HAS BEEN ISSUED.b 7
1 Home Phone !T �6 ash
1. Permit Re ue d Bv i '//g 1� Business Phone
a o et2's'd�ll�
2. Address -15' _ n
3. Property Owneh if Different than'Above
'J. K • o� . A sa
Address -S ';00V0 - &0
4. Permit To: a) Insta ' Alter .. Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. LolNd
5. System used to serve what type facility: House Mobile Homev Business
IndustryOther
b) Number of people
. 6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions/&:?x 7 D -1
Bed Rooms 2-- 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: i
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public—Private--,,,,-
Community i
b) Has the water supply system be approved? Yes No
9. a) Property Dimensions—
b) Land area designated to building site e e,
s
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,'This,sis to certify that the information is c ct to the best m nowledge.
ate Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: f
DCHD(6-82)
ttirie (1�ottn#� �ettl#f� �e�ttr#men#
nub Pence Pealt4 �gentg
P. O. BOX 665
fflackoville, �qarth Carolina 27028
OFFICE OF THE DIRECTOR TELEPHONE
(7041 634.5985
October 1, 1984
Willa Van Eaton
2259 Creston Avenue
Bronx, New York 10453
Ms. Van Eaton:
On September 17, 1984 this office did a soil/site evaluation
on a l acre tract of property owned by you, located just off
Highway 801 in the Farmington Township of Davie County, N.C.
The purpose of said evaluation was to determine the tracts suit-
ability for the installation of a ground absorption sewage dis-
posal and treatment system.
Based on the presence of a very heavy 2:1 shrink/swell clay
(Montmorillonite) and shallow soil depth to saprolite, this
office classifies the lot unsuitable for any ground absorption
system. Upon your request we will have our state Soil Scientist
evaluate the property.
Please find enclosed a copy of the laws that govern sanitary
sewage collection, treatment and disposal in North Carolina.
If we can be of further assistance please feel free to call.
Sincerely,
� A Wei�k//,
Robert B. Hall, Jr. R.S.
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