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P5904 Spillman Rd DAVIE COUNTY HEALTH DEPARTMENT OD IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a N', Sanitary Sewage Systems / / Permit Number Name l,�'/./' u,'r .7. X*7i{�nn�e AIV—4&14e Date `�/�f A) N2 5 9 0 4 Location frs / j �,"%/ I rJ J /fin• " ` /111'C-0 . Ai,11 ,17/ � Subdivision Name Lot No. Sec. or Block No. Lot Size e House .�, 1 Mobile Home _ Business __ Speculation No. Bedrooms No. Baths � No. in Family _ Garbage Disposal YES ❑ NO ©- Specifications for System: Auto Dish Washer YESNO [-] /0��6 Auto Wash Machine YES j 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. r-- may/ �.✓ 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. v Final Installation Diagram: System Installed by 7 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. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P� ,1 P. 0. Box 665 Mockaville, NC 27028,. Cr � D OCT 5 Application ermit Requested By UJ•C� �Avi.s f7R. /�� 7u,,��,.f��� Mailing Address r��v �'� Home Phone Business Phone --�— 2. Name on Permit if Different than Above 3. Property Owner if Different than Above k!•tt��$�J,/IM�4W • 9�:3�98ie ,://�apolf� 4. Application/Permit For : R--,*;Ieneral Evaluation S/Tank hnstallation 5. System to Serve: &-House 1D Mobile Home Q Business Industry u Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Loti No. of People Dwelling Dimensions No. of Bedrooms Basement/Plumbing No. of Bathrooms 71 Basement/No Plumbing 0 Washing Machine �j Dishwasher Garbage D-isposai ' 7. I.f business, industry, other: Specify type 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: 0 Public 0 Private n Community 9. Property Dimensions li Q,&U-&' 10 . Sewage Disposal . Contractor 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? Yes 0 No If yes, what type? J� *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject iI to revocation, if site plans or the intended use change. - Effective October 1, 1989._ --__- :i This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. Date - 8ignature Directions to Property : /ems �. S�-i/•.�.,� .Q�- 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,tMocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED (office use only) 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 SIGNATURE DCHD(11/84) ( ' - DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION 1 Name Date Address Lot Size � C FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S` S /IL-n 2) Soil Texture (12-36 in.) Sandy, , S Loamy, Clayey, (note 2:1 Clay) C' U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils K5;1 <Zpp dv elfs- U U U U 4) Soil Depth (inches) S S ---& 0 U U U 5) Soil Drainage: Internal $) (:�P P U U U External ,S,_ S � k U /"CjP,S� U U 6) Restrictive Horizons 7) Available Space S S S S S 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 ZS-Provisionally Suitable Recommendations/Comments: Described by /ZW- Title Date SITE DIAGRAM S u UCHO(6.82) Davie County .dealt!• Department and .dome Nealt!i Ayency 210 HOSPITAL STREET/P.O.BOX 665 MOCKSVILLE.N.C. 27028 PHONE:(704)684.5985 October 12, 1989 W. W. Spillman . Rt. 2, :Box 402 Mocksville, NC 27028 � ,✓ , t Re: Site Evaluation W. C. .Davis, Jr. Off Spillman Rd. Dear Mr. Spillman: On October ll, 1989, as you requested a representative from this office visited the 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, Robert B. Hall, Jr. , R.S. Environmental Health -Section RH/wd Enclosure