392 Peoples Creek Rd ;�� •`-♦ •-- _. __• :,P.i, ,.r. - wry - ,o-... ! TM IS'. ,c ..,..-.-........ _ ,.....- ...,_ - .: ,'
a
DAVIE COUNTY HEALTH DEPARTMENT
. ._IMPROVEMENTS, PERMIT AND CERTIFICATE OF COMPLETION
`NOTEf-ssued in Compliance with G.S. of North' Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal ,Rules (10. NCAC 10A 11934-.1968 Permit Number
Name �/Y,;r>,�%�:� � ,�./ Date 0 4630
I; Location z- /�, Q� ;�" �. C
Subdivision Name Lot No. — Sec. or Block-No.
Lot Size House - �� Mobile Home !' Business Speculation
i, No. BedroomsNo. Baths - _ No. in Family
Garbage Disposal YES '❑ NO ❑. Specifications,for.Syste '
Auto Dish Washer YES O NO �` .moi -
Auto Wash Machine YES ❑ NO ❑ �!
Type,Water 'Supply --
*This permit Void if sewage system described below is not installed within 36 months from date of. issue.
If ti
i 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.
±i Final Installation Diagram: System Installed by
X00
i 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.
a
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
We . ' � Davie County Health Department
Environmental Health Section
Cavi S 1 Cke { % nc)c. (_L 1(c ku S i P. O. Box 665 ' •�_
( Mocksville, N C. 278
02 ;r "L
�-�n t s lct nd cl way ` � done,
CONSTR CTION SHALL NOT BEG N UNT L IMPROVEMENTS PERMIT HAS BEEN ISSUED.
pc vN -, u C-
ReHome Phone
1. Permit queste�j By �� w• ��G� 1 Business Phone
2. Address � �a I�iVCr�1,e�a l o).;,.� �no�,�S� �Iu4mcc- L C� 27boL
3. Property Owner if Different than Above
Address AUcinrc_ 1�•C
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility. Housed Mobile Home Business
IndustryOther
b) Number of people 4
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 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? Yes No
9. a) Property Dimensions Z'?A,
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Pe or 10-5 Cr2ZLC A"4 ►n Itr yo1A See-
�'vll�w
DCHD(6-82)
t •
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: DATE RECEIVED
(office use only)
yes 1. 1 am the owner of the above described property.
no 2. I am not the owner of a above de
ri d ropert wever, 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 conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
D A-YE 6IGKATJRE
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
Anyone requesting results
Only those listed below
4F7
DAT SI A URIf
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
~^` P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Jw � 6e lz Date a—f"" _�7
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) SS S S
PS PS PS
U U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
PS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space � 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:
Described by l� Title Date
SITE DIAGRAM
DCHD(8-82)
. Davie County Neali De artment
an dome NealtFr Aen
21 O HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE:(704)634-5985
December 29, 1987
Mr. David Miller
Rt. 3, Box 200
Advance, NC 27006
Re: Sewage System Installation
Jack Howell Residence
Peoples Creek Road
Dear Mr. Miller:
The septic tank system that serves the Jack Howell residence on Peoples
Creek Road was designed and approved by this office.
With proper maintenance the system should function indefinitely.
Sincerely,
Robert B. Hall, Jr., R.S.
Environmental Health
RH/wd