363 Potts Rd DAVIE COUNTY HEALTH DEPARTMENT
` IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
+ Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name — Date `5--Z3—e3 i' a, 3291
Location lafls Rosa Lffa l
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home 1,0'f Business —_ Speculation
No. Bedrooms �— No. Baths 2 No. in Family —
Garbage Disposal YES ❑ NO [2' DSL
Specifications for System:
Auto Dish Washer YES ❑ NO p"
Auto Wash Machine YES NO ❑ 3110 x3 Y/
Type Water Supply 'k+((1 ---P'k,)U' /✓o 660+htA 3d MtVP ^#`q
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
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 f\,Ac
3 "
Certificate of Completion Date ZJ'-9
'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
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date 5 11-8'3
Address 31.OV SLA, Ll- UL— Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position 3) <2r-5 S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) e_ �cm PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils 2:12& 4!:M5 PS PS
U U U U
4) Soil Depth (inches) S S S S
t:M PS PS
U U U U
5) Soil Drainage: Internal S S S S
_Zr!§ -M�) PS PS
U U U U
External S S
PS PS PS PS
U U U U
4
6) Restrictive Horizons
7) Available Space 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 -Q 1'Y1a, .� - Title �^� Date
SITE DIAGRAM
3A _ --
F
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested ByiA ,FOX ig/xv I e. Business Phone
2. Address d, ' -
3. Property Owner if Different than Above
I'
Address 3�O � SXta 04 40_0-�5 Ale— k�► _�, Iy,� . r�7//�
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: House Mobile Home L""'Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms Z 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—
b)
imensions 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 corr t to the be f m e.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIA WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Exti 7a go l 50-,f7ll ow go/ T P 7 d
76
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTIMENT
SITE EVALUATION CONSE14T FORM
INSTRUCTIORS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2. Along with the form, remit the amount due as shown on enclosed statement.
3. Carefully follow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO THE(DAVIE COU[JTY HEALTH DEPARTMENT,P.O. BOX 57)
(t.10CKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTYXNT
SITE EVALUATION CONSENT FOR1-I
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
yes no (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described property, however, I
1 certify that I have consent from 0,9,e, 1, /�/� ,owner to owner's name
obtain a site evaluation by the Health Department for the purpose
of determining the suitability for a ground absorption sewage
disposal system.
yes no (3.) I 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 necessary to
determine its suitability for a ground absorption sewage
disposal system.
DATErath
TURE
(4.) I hereby authorize the Davie County HDepartment to release
site evaluation results from the abovribed property to the
following:
0 Owner Only
E3 Owner's designated representative
nyone requesting results
DATE [2 Only those listed below
GNATU
�tti�ie (1�uun#� �ettl#� �e}�ttx#men#
ttn� ��me �EttI#� c��Pntg
P. O. BOX 665
f urksitille, North ( arolina 27LIZO
OFFICE OF THE DIRECTOR TELEPHONE
1704) 834.5985
May 23, 1983
Mr. Dennis Mabe
3608 Shady Acres Lane
Winston-Salem, North Carolina 27107
Mr. Mabe:
In regard to the property on Potts Road where
you want to place your mobile home, please contact
this office so I can meet you at the site. I am not
sure as to your proposed location of the mobile
home.
Sincerely,
Joe Mando, R.S.
jh Env. Health Coordinator