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1988 Milling Rd �5�.. .. . . _ . - . . . . . � � � . . . . ` � . " �! . •(i 4-` � . �`„� ' �" :� y DAVIE COUNTY HEALTH DEPARTMENT . �/��, `�' � ` � ��•� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION � T , *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a !F- - � Sanitary Sewage Systems �----Permif Number I :- /) � Name i` `:� �r �' -�'`�f t�� '-�'r-�i�.'`l"' '/� �j♦ ^ —�-- �' ,.° ,', ' r �f+lPi .x ! �O �� `. , �. � �, : i . Locatio � ' � � - �_ ,:. _ � �.�/�_,. ,� i,r� "" .,, rrr . : , ;�r �, / , ; . ' . : , ,. .�� .- : = •, . , � .�,. ,;, .� .- �, �' Subdivision Name Lot No. Sec. or Block No. .� • � Lot Size_.�.�-`� �� House Mobile Home _�"' Business -- Speculation �--''� No. Bedrooms _�..��_ No. Baths _.--� No. in Family _ Garbage Disposal YES ❑ NO �� Specifications for System: Auto Dish Washer YES NO ❑ -.,,, ,.� �, �`� ,..-;-. Auto Wash Machine YES � NO ❑ '�'� �"F �'j r `y'"Y� � `'J �-M� _. , -, �-� �,i r.7 f ��j t� Type Water Supply , � --- �`:.:;;,� ,, .: r� �'.� '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. ��, � '�,�� ,� �,� \ �r �/ r....., �� ., �``\�-�S_ �4 �-p J'� '.� ��_. ��_�._��,�.. �� ._. . �._. . !'C �` ` �� _ \ . . i,J �.,...«.,,.....,�..., `�:c. � . ,,..,,,.�.,..,, ...,�,,..,...-�..ti \��.,`` � � ��....�-..�.......^'�,.^'_,.,..._.......�.,.�.,, . ,. �»,.�_�r�� t� � , y.-�' _.,.._.....---^ �Z""""^'""..'_._..,.___._.._..�...-,--.�_....'...•- ��-..�^---�.._..._.....M.._.. -- ^"' "------" "`�.,..�.,,..,...�........_.._,.._.....-------""""'.-' 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 ��- ��'�� _ ,�, �,� � �� _..._----- � � _.,_--- �_._._ l;";.,.,j ; "�-� � �z , �._____--._,�� c_.,,_......_...__.�. ._...�. ,� .s' _� �.._____ y j_..._ --�� a 5` ...,>._ -_..��,._ !,.,�'"tr � -----��_'-�-.—,�.`�'�___,. l,� `�~—�---�-...._.__ / % , , � � Certificate of Completion f f�`%�� f Date `� r a� � �/�- �, , "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. . � �� y__ � . . ._ . /i. 'oa " e°'`•Y'�;`-�..i DAVIE COUNTY HEALTH DEPARTMENT �/Xo � �- - "-�� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLE710N ' � � 'NOTE:Issued��inComplianceWithArticlellofG.S.Chapter130a. q � � V - � %. 7'� •' Sanitaiy Sewage Systems ��Permi( Numb'er Name `.l �' ./�> ��s'I�A�/.///l'/ i/ oate �1-4l- r// N� 6275 . , Locatio .�//-.:.,. .P./ - �!/,.i � fl.:>n�r �,��sr,✓. �.,G � �JJ- ' '- �'�. , v Subdivision Name Lot No. Sec. or Block No. Lot Size �f�� House Mobile Home _� Business Speculation �� No. Bedrooms �� No. Baths � No. in Family Garbage Disposal YES ❑ NO p� Specifications for Sysrem: Aulo Dish Washer - YES 0 NO ❑ ✓ �D Auto Wash Mechine YES � NO ❑ /��`f((�"� � -�F Type Water SuPP�Y � --- ��UX?X/.� �• 'This permit Voitl it sewage system described below is not installed within 5 years irom�date of issue. 7his permit is subject to revocation it site plans or the intended use change. (� d'� y�� p,/ B �^- � � � � L 0 � � . , , � � Improvements permit by ��/ 'Con�act a representative of �he Davie County Healih DeparimeN for final inspec�ion of this system belween 8:30- 9:30 A.M, or 1:00-1:30 P.M. on tlay of completion. TeiephoneNumber: 704-634-5985. .. n ✓ Final Installation Diagram: System Installetl by 0�� - //♦ �/ � �do� � ,' ( as v ,� s �� Certificate of Completion _/"�'7 (/ Date '�/'/9� 'The signing of this certificate shall intlicate that the system tlescribetl above has been installed in compliance with ihe stantlards set forth�in��theabove-r,egulation,but shal� in-NO way be taken as a guarantee ihat the system will function satisfactorily for any�given period of time. . �y�"�, � � � '' � .` � r•` � B��APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ` � Davie County Health Department � � Environmental Health Section � P. O. Box 665 �c� �� Mocksville, N.C. 27028 � F��JAH � � � - � CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone �9`�� ` P�?—`� 1. Permit Requested By NQ-'�v��^�-� Business Phone 2. Address ��. 3 ��• G�/ .�oox.��,/�c 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair �„ ,�,� � P,.�,;,.(,r(,. �.,� �Pa�k b) Privy Conventional Other Type � g;,� Ground Absorption �. c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home_��Business Industry Other b) Number of people 6. aj If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms�_Bath Rooms -2- 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) �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? Yes � 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? What type? This is to certify that the information is correct to the best of my knowledge. /-/7 -8�l /[ ��..� �. ��/h> Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: /h://�f �� - '/2 rv.�1.�. Q�...�. ��.--�I.�..._. e��. �... ��- �t,JOI r� z �`� �s t,�' - ��t:�.J�.... �- GQ.. �.... . �y -� ��- � . �- Z 3'��l a.4P ,ctu1�u f � t��-�.., � � _� _ - �--� - � o �-� � �� DCHD(6-82) . ��. . '• L .'� � r.' ` pAVIE COUNTY HEALTH DEPARTMENT ' Environmental Health Section ' P. O. Box 665 Mocksviile, N.C. 27028 SOIL/SITE EVALUATION Name OV 'Q':�c��N � rcc�` � � Date I � �� - �� Address S A � � Lot Size � � FACTORS AREA 1 AREA 2 AREA 3 AREA 4 ��d�� 1) Topography/Landscape Position ,� PS � �I� PS U U U � 2) Soii Texture (12-36 in.) Sandy, S Loamy, Clayey, (note 2:1 Clay) PS US � �� 3) Soil Structure (12-36 in.) S_, S� ,S��) Clayey Soits � CS � �.�S� U U U U 4) Soil Depth (inches) � S� �� U U U U � 5) Soil Drainage: Internal g S � �' PS' �,:� � � U U U �' Externai PS �.P � �S � U U U U 6) Restrictive Horizons ��' 2fiDj �----_ v� ` �y 7) Avaiiable Space PS , US � � � U U 8) Other (Specify) S S S S PS PS PS PS _ U U U 9) Site Classification � -- �S � S ? U—UNSUITABLE S—SUITABLE PS— rovisionaliy Suitabie Recommendations/Comments: ��.4-�-'-" \ ��-.�y Q�..c� s.� - � fio � ' �� ,�-+��4 _�.o��•� �� d--c�� . � �_ - ��eM 5 a-� 2,t o \ �v�. ��tN..�1J c�v Described by _\•��- Title � � Date �'2� �� SITE DIAGRAM _._._.._. � �S � � � � � � �� `c� �S2 � ��, �S C� � . �� b C� � � DCHD(6-82) ' , �� ' `•' �avie Courrty .�lealff�i De arfinenf and .�fome �leal�i yency 210 HOSPITAL STREET I P.O. BOX 68S " MOCKSVILLE.N.C. 27028 PHONEs(704)834-5985 January 31, 1989 Nathan Smith � Rt. 3, Box 661 Mocksville, NC 27028 I2e: Site Evaluation Milling Hoad �' Dear Mr. Smith: On January 27, 19a9, as you requested a representative from this office visited �he 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, �_ St�� Charles E. Little, R.S. Environmental Health �Section CL/wd Enclosure • � �,. _. , .. DAVIE COUNTY HEALTH DEPARTMENT �' Environmental Health SecHon PO Box 848/210 Hospital Street Mocksville,NC 27028 -- Phone: (336)751-8760 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) REPLACEMENT�r'' REMODELING ❑ RECONNECTION ❑ Name: �� -�,�''y'��jr��'� Phone Number: �� (��.- (Home) Mailing Address: �f��.�%/1 Q 1�f�+ �('� t_�,�n -��„� (Work) ;��r��,�/l� �i.��'., ,=�%?l�7_� � 7 / �.-- � Detailed Directions To Site: P��i � 1�= ��!- r�a( -1 1"d�� c��iC �5�� ')�'-�7r , ��' ��'t� r .� .� r,� 1 /` � `�� 'J /o� --�i ls i1/� ;�' 1-�r' � ��l� �� "/T � -r- r / � Property Address: l T� i � � ( `��. ��??i �1 i'� 'l/1a�f% ��'c' ,l �J 2.. �GfJF':�� r Please Fill In The Following Information About The Existing Dwelling: Name System Installed Under: ��l�fti� f.��(� Type(�f Dwelling: ��U�'i <' �'`7 �/''J� Date System Installed(Month/�Day/Year): -�C/�l Number Of Bedrooms: � Number Of People:T_ Is The Dwelling Currently Vacant? Yes�No�. If Yes,For How Long? .�- Any Known Problems?Yes❑ Nb,��l``° If Yes, Explain: Please Fill In The Following Information About The New Dwelling: /7; ., � Type Of Dwelling:��"�t� � �� r �fE..- Number Of Bedrooms: i Number Of People: - Requested By: Date Requested: .+""' �`�l��r� (Signature) For Environmental Health Office Use Only Approved �Disapproved 0 Comments: � � � f t�� Environmental Health Specialist .f �.�i/E�' Date �/�� C�``� "'"r`� • 'rThe signing of this form by the Environmental HeaYth Staff is in no way intended,nor should be taken as a guazantee(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 #: ';�,'� �i�� ' ��Q� Invoice #• l��d�-"