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138 Sparks Rd (2) Davie County,NC Tax Parcel Report Monday, October 17, 201 c ' 172 159 158+i 136 i i 13 1400-, 1366 k I I i I K�ly 1 Y 1357 !. 189 ��.,.�� � 1413 r i 1446 rf' 245 } �J� i ..........................._.................._....................................... ........_.._................. ..................................... - _......._..........................................._ ........................................................................................................ WARNING: THIS IS NOT A SURVEY Parcel Information Parcel Number: B70000000804 Township: Farmington NCPIN Number: 5863256220 Municipality: Account Number: I . 51145750 Census Tract: 37059-802 Listed Owner 1: MINER MARK A Voting Precinct: FARMINGTON Mailing Address 1: 138 SPARKS ROAD Planning Jurisdiction: Davie County City: ADVANCE Zoning Class: DAVIE COUNTY R-A State: - NC Zoning Overlay: DAVIE COUNTY QD Zip Code: 27006-0000 Voluntary Ag.District: No Legal Description: 4.49 AC SPARKS RD Fire Response District: FARMINGTON Assessed Acreage: 3.64 Elementary School Zone: PINEBROOK Deed Date: 8/1987 Middle School Zone: NORTH DAVIE Deed Book/Page: 001390348 Soil Types: PcC2,CeB2 Plat Book: 11 Flood Zone: Plat Page: 160 Watershed Overlay: DAVIE COUNTY Building Value: 121960.00 Outbuilding&Extra 0.00 Freatures Value: Land Value: 58840.00 Total Market Value: 180800.00 Total Assessed Value: 180800.00 9 t /� All data Is provided as Is without warranty or guarantee of any kind either expressed or implied Including but not limited to the Davie County, implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to W11 -1 NC or arising out of the use or inability to use the GIS data provided by this website. RECEIVED WELL ABANDONMENT RECORDFar Internal Use ONLY- OCT 0 016 This form can be used for single or multiple wells 1.Well Contractor Information: .L ABANDONMENT DETAUZ D6 HEA1 TH 7a.Number ofwellsbeing abaodooed: ;Well Contractor Name(or well owner personally abandoning well on hisMer property) For multiple InJecrlon or non-water suppty wells ONLY with the tams consrrua/on/abandonment,you can submit oneform. •' 7b.Approximate volume of water remalriing in well(s): 30 (gal.) NC Well Contractor Certi6cation Number W—le" -6n if, FOR WATER SUPPLY WELLS ONLY: Company Name t 7e.Type of disinfectant used: 1.Well Construction Permit ff: GI ZA Lisroil applicable well construction permits(l.e.Coun�e,Parlance,eta)Ijlnown 7d.Amount of disinfectant used: ' c tv 3.Well use(check well use): Water Supply Well: 7e.Sealing materials used(check all that apply): ❑Agricultural ❑Municipal/Public ❑Neat Cement Grout ❑Bentonite Chips or Pellets ❑Geothermal(Heating/Cooling Supply) • Lesidential Water Supply(single) ❑Sand Cement Grout ❑Dry Clay 01ndtutrial/Commercial Dkesidential Water Supply(shared) )(Concrete Grout D brill Cuttings ❑Irri ation Cl Specialty Grout D Gravel Non-Water Supply Well: ❑Bentonite Slurry D Other(explain under 7g) ❑Monitoring ❑Recovery Injection Well: 7f.'For each material selected above,provide amount of materials used: ❑Aquifer Recharge ❑Groundwater Remediation ❑Aquifer Storage and Recovery ❑Salinity Barrier �C• ❑Aquifer Test ❑Stormwater Drainage ❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure: ❑Geothermal(Closed Loop) ❑Tracer .��/� ❑Geothermal(Heating/CoolingReturn)_ ❑Other(explainunder7 rL/� d — —` r Ogg in n00G-,n r2" 4.Dalc wcll(s)abandoued: 5a.Well location: Facility/Owner Name FacilitylDN(ifappliesble) 4 a.Cerulieation: 13 SR;L1, P U -;W VI fl. 9- . Physical Address,City,andtip Sign of Certified Well Contractor or Well Owner Date V1 By.signing this form,1 hereby eertffy that the svell(s)eras(ivere)abandoned in County Pamcl identification No.(PIN) accordance with ISA NCAC 02C.0100 or 2C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner. 5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: (ifwcll field,one lat/long is suf client) 9.Site diagram or additional well details: 3 (� N Q/6 5i q 3 W You may use the back of this page to provide additional well site details or well �G I /} 73 C abandonment details. You may also attach additional pages if necessary. F.9 STRUCTION DETAILS OF WELL(Sl BEING ABANDONED �1�BMITTAL INSTRUCTIONS Attach well construction record(j)%avollable. For multiple In)eerion or non-water supply ,rellsONLY with the some consrruct/on/obandonment.you can submit oneform. 10a. For All Wells: Submit this form within 30 days of completion of well Ga.Well IDli• abandonment to the following: Division of Water Quality,Information Processing Unit, 6b.Total well depth: '(� pn, (ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617 10b.For Infection Wells: In addition to sending the form to the address in i0a above,also submit one copy of this form within 30 days of completion of well 6c.Borehole diameter. (in.) abandonment to the following: �� Division of Water Quality,Underground Injection Control Program, 6d.Water level below ground surface: -(ft) 1636 Mail Service Center,Raleigh,NC 27699-1636 - �10A jC `7 10t.For Water Supply&Infection Wells: in addition to sending the form to 6c.Outcr'casing length(if known): 1 (fl.) the address(es) above, also submit one copy of this form 'within 30 days of completion of well abandonment to the county health department of the county 6f.Inner casing/tubing length(if known): �- (ft.) where abandoned. 6g.Screen length or known): (ft.) Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water QualityI /,l Revised March 2013 Well Certification of Completion For office Use Only Davie County Health Department *CDP File Number 210 Hospital Street PIN Number: t � P.O. Box 848 Tax Lot#: Tax Block#: Mocksville NC 27028 Evaluated For: Phone:336-753-6780 Fax:336-753-1680 Properly Owner: M6rjO ft A'Ngor Applicant: Address: 13S Spa r-�S Address: City: City: State/Zip: State[Zip: �P�hone Phone#: Directions Drilling Contractor ,UJE,L ,L-, Driller Registration Date Drilled C) q / 1 ti / 0.1 U Replacement Well R Yes [:]No Total Depth Ft Use of Well Static Water Ft Yield gpm Water Zone 1) Ft 2) Ft 3) Ft 4) Ft Chlorination Type: Amount: t ng: Depth:-----,5 oFt Thickness �C6In. Diameter (p In Top of Casing��In. Material Grout Depth Material �e�„i�n,A Methodpu-mq�, ��h Material Metho o�.I .To. .Ft From. To. Ft. From, /f From. �To. QFt. Cf1 I 'Liner Date:O.9. 1 2 / 2 0 1 6 From. TO. Well Driller Signature Grout Inspected by: EHS# 'Signature Date;0 9 / 1 a / a 0 1 6 Issued by. =Date: 0 9 / 1 2 / 2 0 1 6 Location: Tee (het) Yes �No Comments C titudengitude: Suction Line Yes �No Temporary Yes �No sure Yes No Well I.D. Plate Yes [:]No Enclosure Floor Yes ❑No Pump I.D. Plate F]Yes F-jNo Access Port [:]Yes n N o Vent []Yes ❑N o EHS: Bib Cock R Yes []No Issue Date: Back Flow MYes F�No Water Sample Yes n No OHand Drawing Olmport Drawing h R APPLICATION FOR PRIVATE WELL PERMIT Davie County Environmental Health P.O.Boz 848/210 Hospital Street Mocksville,NC 27028 (336)753-6780 1 Fax(336)751-8786 ***IMPORTANT*** THIS APPLICATION CANNOTBE PROCESSED UNLESS ALL OF THE REQUIRED INFORMATION IS PROVIDED. APPLICANT INFORMATION n,1 Name to be Billed [AU1 A 4 A N n'et Contact Person ArAN•Irl iw Billing Address 3?);c KS Home Phone G Z-1 N7 ity/State/ZIP � )G�nc�, N DIo Business Phone 331j-c133-3Uc4 Email Miner,cA �,�.,1& M&,,l,['afn 331. yL1-u�2 ame on Permit if Different thail Above Mailing Address City/State/Zip PROPERTY INFORMATION *Date House/Facility Corners Flagged OTE: A survey plat or site plan must accompany this application. Included: Site Pl Plat (to scale) Owner's Name P-rnN -}k, l Phone Number 33b-g6W-11S 1 Owner's Address 3 Sqo--yr. Q a- City/State/Zip BA00C�-U 1J(- V 700L operty Address " City_ -L fiL Lot Size LI.LAQ Nc- Tax PIN# 6-IOGOe DOCI90LI Subdivision Name(if applicable) 011 Section/Lot# Directions To Site ML(0 LL'V9- �o P�01 Qot+, ,Tum 12(� mM o U at k,t rl �P-JA RocA. 3,Z rc,n -fib arou,,3 S� C.wtte. V-tr�� cl.�c•iU� crn DEVELOPMENT INFO TION Permit Type: New Well Well Repair Well Abandonment Other(specify) Facility Type: Residential V/ Food Service Churc Commercial Other Are There Any Septic Systems Currently On The Site? YESy NO Do You Intend To Install A New Septic System On This Site? YES NO TERMS AND CONDITIONS: This application must be accompanied by a plat or site plan of the property that includes the existing and proposed property lines with dimensions,the specific location of the facility and any existing or future appurtenances,the location of any existing septic system,sewer lines,water lines,any existing water supplies and any surface waters. The applicant is responsible for identifying and marking the property lines and corners. The applicant is responsible for making the site accessible. By signing this application,the applicant signifies that they understand the terms and conditions and that they give permission for Davie County Environmental Health representatives to perform necessary field evaluations and procedures deemed necessary to determine the best location for a well. dA. Signed Date Site Revisit Charge Date(s): Tient Notification Date: HS: 7/30/09 Account# Invoice# too'or(,I r;,<<•r New Well LJ 200'or Greater 200'or Greater Current Well• Gt t QO 200'or Greater 04 ti N� Septic Field Garage Mccf,L A w (firvuyH M�cw 138 spcsl�5 p cl '72' i 36 f Sf E N 'CLE� E { S 2SOO N w M WEA I, 4v 'Rs P(uA 61041 �p i` ;� �� lSo�•>ro 3d' Secnk F�E�p 3oxtiv �ti �� �fi To Pr.P'l.►NE • I r tAiZ►� ? eAm�t I V` I n�En. )2S' s�RR��S 12L� �.. "i".'if;i:..eri;>�7r�:t.� ��7�$'`N.ryn��[iq.,,.4 -t>. '.ten h.^.N.}�."t :,,:___:.^n rfa —C'• . r. .i Ali r 7:. .+ . r- . n �U• o i f �'.5� ✓X0 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Name / Date N2 7556 Location Subdivision Name Lot No. Sec. or Block No. Lot Size House 1-�Mobile Home _T Business -- Industry No. Bedrooms No. Baths - --2 No. in Family — Public Assembly Other Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES Q NO ❑ Auto Wash Ma thine YES ❑ NO ❑ Type Water Supply *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. 1 Improvements permit by — L *Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed byi�` f 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, 4(0 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND` CERTIFICATE OF COMPLETION r "NC�TE.lssued in Compliance With Article II of G.S.Chapter 130a Permit Number ����anitary Sewage Systems � �� 9 NO Name -. ,'Yzar �7`�� 'S;�t�/1✓' Date - 7556 Location Subdivision Name 'I Lot No. Sec. or Block No. Lot Size IVA House �~ Mobile Home — Business -- Industry No. Bedrooms S? No. Baths — -'9 — No. in Family _ Public Assembly Other Garbage Disposal YES ❑ NO ❑ Specifications for System: ' Auto Dish Washer YES ❑ NO ❑ Qa��� Auto Wash Ma-.hive YES ❑ NO ❑ �� Type Water SuPPIY *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 inten ed use change. ,i t c 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., 1:00-1:30 P.M.or 4:30-5:00 P.M.on day of completion.Telephone Number:704-634-5985. Final Installation Diagram: System Installed by zL� � k 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. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 17 30a Sanitary Sewage,Systems Permit Number Name %• .> �, �;� .t` ;!/�Y{ .%f%-�: Date IQ Location Subdivision Name Lot No. Sec. or Block No. Lot Size r-'yl House Mobile Home _ Business _— Speculation i 'No. Bedrooms No. Baths _ _ No. in Family Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto Dish Washer YES ❑ NO ❑ : a./, ��' Auto Wash Machine YES ❑ NO ❑ Type Water Supply *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. l" - J- Improvements permit b *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 ��/ '�=J�►��t- JG i1" Certificate of CompletionDate 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. • APPLICATION 'FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health DepartmentO Environmental Health Section `vED OCT 2 3 P. 0. Box 665 RECE Mocksville, NC 27028 1 . Application/Permit Requested By Mailing Address Home Phone 4l/9.179Y-9„2,:�7 Business Phone 2. Name on Permit if Different than Above 3. Property Owner if Different than Above 4. Application/Permit For : General Evaluation @,,-S/Tank Installation S. System to Serve: [House Mobile Home Business lC) Industry Other Unknown 6. If house, mobile home: Subdivision Sec. Lot# No. of People / Dwelling Dimensions G No. of Bedrooms / Basement/Plumbing /a. of Bathrooms / ` Basement/No Plumbing @/Washing Machine Dishwasher 0 Garbage Disposai 7 If business, industry, other: Specify type �f ��'� No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers 8. Type of water supply: Q Public Private Community 9. Property Dimensions "2dd X dsS X s'0xa7' 10. Sewage Disposal Contractor fiah/c 7'i-A-1soJ 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? Yes R-No If yes, what type? *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plane or the intended use change. Effective October 1, 1989. This is to certify that the information provided is correct to tree best of my knowledge, and I understand I am responsible for all charges incurred from this application. /D a3-rrd 214� Date Signature Directions to Property : //aa v ,SDH/�d 4.4Co... LQFr, Ga ar�...a� c✓r✓s- i/ �� y i.0 .E,r.�i/.c� /�o..lc !io✓�e �.,� DCHD . (10-89) ~ 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) u/fc3 /� •••� 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 _Anyone requesting results — Only those listed below DATE SI NATURE DCHD(11/84) 00. 57 PG.1 - i GRANITE GRANITE MONUMENT S 87•:23.15"E -----r 1162.99ONj)MENT J m 472.00 NIP 332 66 NEW 138.43 200.00 t Z - - IRON N 02*36 45"E I F G.1, HANES f O wO r 5040 zo o N AREA = 1.796 ACRE Q3 t t9 (. A„•AREA=0.M y, O ' (INCLUDES SR 1455 R/W) "`' b mSPLIT FOYER ACRE E `T 6 p w/BASEMENT Z MARK A MIN R EIP D8.139 107.40ti N 13479 ti c N 86•.33'04”W _ _ 9.6 N EIP 79 _x..w + g porch 'o 6O (675) +ap0 6 ' o�troo9 r N 57°458"W r , + AREA'-;-6.315: N 27'03.14"W INCLUDES SR 1455- _ W 31.18 TOTAL `n - ~ AREA = 2.000 AC. N 87°32 365"W . + - ~ N 4100854,.E v o r SURVEY FOR: MARK A. MINER &.w/ N 09'40*59"W p n AMELIA H. MINER o F. DAN TATUM h F D8•:121 PG. 547 254.84 3 N 05'03'071'W p e:.,-532'36"E AREA= 0842 AC. 0 o 11 ip M MARK A. MINER N Q 1 O A 013.139 PG. 348 n ! H N 17'56.39' W p NIP t.,,. tl I _ N'80'32'29-w s µ + I 3 249.17 N1P t XQ N 35'50',49"W \ ^ t- w s Q o ` + AREA= 1.054 AC. A W l N 40452'41"W 99 N n 9� 20.19 00 O ^ (INCLUDES SR 1455 R/W) O �O PV) b ~ ' '26-28 + SSB t * N in el r, O y ~ i * 65. 0 NIP ryh O� � in �.�, 161.91 2^ r S 82 35{9 165.70 3'� Ip o 11 HUBERT HAYES,JR. 195.50 TOl E-� 84'30* 31"E—l<*34 rn OB 117 PG 464 \S 68'37-29"E S 60'44' 59••E l� S 49'29 35'•E b S 0�1'23' 37•'E � 5 4? O?•26••E i S 05'510'56"%% 1 N AREA= 3.731 ACRES S 2,•22005 E�- ; r •- DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME ///>YIa� DATE EVALUATED ���� 645� ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE 5/5f,¢e'' r' Water Supply: On-Site Well Community Public Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 4 Landscape position .t- L Slope %. HORIZON I DEPTH 3 _-2- Texture groupi Ts- Consistence Structure Mineralogy HORIZON II DEPTH Texture group Consistence ? :1 Structure �e Mineralogy . HORIZON III DEPTH Texture group ` Consistence Structure Mineralogy HORIZON IV DEPTH Texture group Consistence Structure Mineralogy SOIL WETNESS RESTRICTIVE HORIZON SAPROLITE CLASSIFICATION _ LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: � EVALUATED BY: Q LI LONG-TERM ACCEPTANCE RATE: y OTHER(S) PRESENT: REMARKS: LEGEND Landscape Position R-Ridge S-Shoulder L-Linear slope FS-Foot slope N-Nose slope CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope Texture S-Sand LS-Loamy sand SL-Sandy loam L-Loam SI-Silt SICL-Silty clay loam, SIL-Silty loam CL-Clay loam SCL-Sandy clay loam SC-Sandy clay SIC-Silty clay C-Clay CONSISTENCE Moist VFR-Very friable FR-Friable FI-Fizzn VFI-Very firm EFI-Extremely firm Wet NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky NP-Non plastic SP-Slightly plastic P-Plastic VP-Very plastic Structure SC-Single grain M-Massive CR-Crumb GR-Granular ABK-Angular blocky SBK-Subangular blocky PL-Platy PR-Prismatic Mineralogy 1:1, 2:1, Mixed Notes I Horizon depth - In inches Depth of fill - In inches Restrictive horizon Thickness and inches from land surface Saprolite - S(suitable), U(unsuitable) Soil wetness - Inches from land surface to free water' or inches from land surface to soil colors with chroma 2 or less Classification - S(suitable), PS(provisionally suitable), U(unsuitable) LTAR - Long-term acceptance rate - gal/day/ft2 DCHD(01-901 ■■■■...■■■■■■■■■■■■■■■■■■■■.■■■■■■■n■■■■■■■■■■■■■■■■■■.■■i■■E.■ � ■■■..■.■■■■.■■■.■■s■■■■■■■■■■..■ ■■■■■.■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■.■■...■■■■.■■.■e■■.■■■.■■■ ■■■■■■.■■■■■■■■■■■■.■■.■■.■■■■■■ ■■■■■■■■■■■■■■■■■■..■■■■■■■■■■■.m■■■■■■■■■■■■■■■■■■■■■■■■■■.■■■■■ ■■■■■.■■■■■■■■■■■■■■■■■■■■■....■■■■■■■■■■■■■■■■■■■.■■■■■■■■■■■■■■■� ■■.■■■■n■■■■■■■■■■.■■■■.■..■■■■�■■■e■■■■■■■■■■■■■■■■■■.■■■■■ ■■■ ■.■■■■■■■■■■■■■■■■■■■■■■■■■..■■.■■■N■■■■.■■■■■n.■■■■■■■■■■■■■■■■ UMMEMME MEMiii�' �MENNEN'�iEMOMME MENNEN��iMMMMMMWiiiiiii�iiiiiiin ■.■■.■...■■■■■■■■,► ■■.■■■■■■t.i��r■■.■■.■■■■■■..■■■■■■■■■■.■■■ e■■■ ..............................................�..■..■..■.0MEN... . ................................ .............. ................. ■■■■■■■■ ■■■ ■■■■iIL.■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■.■■■■■■■■■■■■ ■■ ................................ ........................... ..■o .................................................................. .................................................................. .................................................................. ■■..■■■N■.■■■■■■■■■.■■■■.■■■.■■.■■.■N.■■■■■■■■■■■■■■■.■■■■■■■■w■ .................................................................. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION , ,/''.' *NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c SgWage'Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name p t, c,� _ i� _ Date ` Location 1V\t? Subdivision Name Lot No. _ Sec. or Block No. Lot Size Housey Mobile Home _ Business Speculation No. Bedrooms 'No...,Baths �=` No. in Family n _ Garbage Disposal YES p NO7,, Specifications for System Auto Dish Washer - YES ©' NO p - Auto Wash Machine, YES f�j/ NOS Type Water Supply --- *This permit Void if sewage system described below is not installed within 36 months from date of issue. i GIr r i ,f Improvements permit by *Contact a representative of the Davie County y yealth D�artment for final inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on day of co p(etion. elephone Number: 704-634-5985. Final Installation Diagram: System Installed bye---'%� �� '��' y s .�%.� , 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. t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ` Davie County Health Department V`O Environmental Health Section o G G` P. O. Box 665 r Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 766-0(.07 (9192 1. Permit Requested By ,4�Qi/, Business Phone 76,7-Saa3 2. Address /06-.2 Will.w 7;,-4c- .A!7T. C/e em.'"o.1S 3. Property Owner if Different than Above Address 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 Business Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions .3o X �a 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 3 urinals garbage disposal lavatory -Z showers o2 washing machine dishwasher sinks 8. a) Type water supply: Public Private' Community b) Has the water supply system been approved? Yes Nom 9. a) Property Dimensions . Pix _5-33' x -132 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 est of my knowledge. 9 Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: 'V 1) Sa Z I—, -M ;/.Jk;, I/4/lc� /ci� . le:j�*r o,mn Yedk-1., t/-Ik;, e r ­4� abOvr 4 Oti.T rL4.1 Ow �2TT J✓ST 4r!'rt/� A �`�R//tr Lc4 4-n d;rr I'-t )S te-4i a /outs eti� r10/,r. �� �fa�is '1.'191 Acro. s R /`rtS DCHD(6-82) ) f r 7 DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION (- Name— Date Address Lot Size_ ` 1 �� FACTORS ARA ARA R AREA 3 AREA 4 1) Topography/Landscape Position S S S S PS PS U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PS PS U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS U U 4) Soil Depth (inches) S S S S PS PS U U 5) Soil Drainage: Internal SS S S PS PS U U U ExternalS S qpD S jPS PS ''Cr' 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 P rovisionally Suitable Recommend t* ns/Comments: �._ Described by �� Title Date SITE DIAGRAM DCHD(6-82)