457 Sheffield Rd 100
DAVIE COUNTY HEALTH DEPARTMENT =. ,
IMPROVEMENTS PERMIT AND---CERTIFICATE OF COMP
tESTION �J
*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
�"-B,I '51456
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Name c ra \..\ �! - ��-'-� �`f.� ,,,� \ Date ��'` — ! _ c(,5 N2 v�r3
Location
Subdivision Nam �\�'�� �� �� \ I-^t No. Se
- J
c. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No.-in Family _
Garbage Disposal YES p NO [�' Specifications for System:
Auto Dish Washer YES p NO.
Auto Wash Machine YES p .NO 2--'
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
T
r
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 �`►
1
f;
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r,y'
c
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.
s �
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P 0. Box 665 RECEIVES ` 0
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Hendrix & Corriher Const Co.,Inc Business Phone (704) 634-5972
2. Address P 0 Box 156 Mocksville NC 27028
3. Property Owner if Different than Above Yadkin Valley Telephone Membership Corporation
Address Courtney, NC
4. Permit To: a) Install Alter Repair No Permit Required
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No
5. System used to serve what type facility: House Mobile Home_
ome Busine
IndustryOther Telephone cange
b) Number of people one (1)
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 one (1)
What type business, etc. Telephone Exchange Building
Estimate amount of waste daily (24 hours) 10 gal.
.7. Number and type of water-using fixtures:
commodes one (1) urinals garbage disposal
lavatory one (1) showers washing machine
dishwasher sinks
8. a) Type water supply: Public X Private Community
b) Has the water supply system been approved? Yes X No
9. a) Property Dimensions 100 X 170 ,
b) Land area designated to building site
c) Sewage Disposal Contractor H.B.Salmons, Yadkinville, NC
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? no
What type?
This is to certify that the information is correct to the best of my knowledge.
March 2, 1989
Date wner Sign ture
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
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
Intersection of Ijames & Sheffield Rds (office use only)
yes no 1. 1 am the owner of the above described property.
es no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from Yadkin Valley Telephone Membership, 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.
es no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described propertyand 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
—Anyone requesting results
xx Only those listed below
Yadkin Valley Telephone Membership Corporation
Hendrix & Corriher Construction Co., Inc.
3-2-89
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION 2
Name ��"u �A . Date J n - I
Address Lot Size OU x J 7 b
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S
PS k
U U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Cj@yev (note 2:1 Clay)
3) Soil Structure (12-36 in.) S
Clayey Soils PS 1 PS
< U -�J-
4) Soil Depth (inches) S S �' S
P PS
U U U U
5) Soil Drainage: Internal S
iF< � PS
U U U
External C
< P
U U U
6) Restrictive Horizons
7) Available Space S S
Ors--' 1 1::P3
PS U
8) Other (Specify) S S S S
PS PS PSI PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: �� M ` 't'n ' --5
Described by Title Date -�
SITE DIAGRAM
end.
Q
u U,
DCHD(8-82)