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178 Oakbrook Drive Lot 14 Section 2Alm DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION "Rote: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. ,Permit Number Name / C��►s?RucTi�n Date 7-- Y'— `��- Location Subdivision Name (�XL�&boi% 1,7,eaLot No. Sec. or Block No. Lot Size House ✓ Mobile Home — Business _— Speculation No. Bedrooms —3LNo. Baths —�"' No. in Family Garbage Disposal Auto Dish Washer Auto Wash Machine Type Water Supply "This permit Void i i i i YES ❑ NO ❑ Specifications for System: 1pv0qa%�6n YES ❑ NO C]300' k 3"A. /Z'� 57'OA/F_ YES E] NO ,D -80X o,v Gd vctrrE if sewage system described below is not installed within 36 months from date of issue. Improvements permit by 'Contact a representative of thte 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: 11ff W 6 , r�1�- 1A fP�• System Installed by S;9 -Z3 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 Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name 'Fb'DIE IAyf3fwiLo T1 V 60NSTTt,Uc-n01J Address GZC( PMR -S ?AR1u,3A,'-f W I N S'lv-- - d CA r`Tn Q C ARCA 1 AREA 7 Date 7 - !R' - Si -L— Lot Lot Size 13 ° X ZS O 3 I? 2 0ATH ARFA 3 AREA 4 Topography/ Landscape Position G) S S PS PS PS PS U U U U !) Soil Texj in Sandy, Loamy Clayey, ote 2:1 Clay) S S PS S PS U U U U 1) Soil Structure (12-36 in.) B�Ky S P S PS S PS Clayey Soils PS U U U i) Soil Depth (inches) ® S S PS "PS yi PS PS U U U U i) Soil Drainage: Internal 0 � S S PS PS PS PS U U U U External S S PS PS PS PS U U U U i) Restrictive Horizons ') Available Space 6) CS) S S PS PS PS PS U U U U 1) Other (Specify) S PS S PS S PS S PS U U U U i) Site Classification 1� S PS U—UNSUITABLE S—SUITABLE PS—Provisionally Suita b Recommendations/Comments: S y STS V'� G o I r� FEZ-�n-��- �A 2-o Described by Sys Title SAN�(A�1 Date SITE DIAGRAM 14?1& 1 C.4 T/ cy✓ lz ��a&7cf DCHD (6-82) DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM INSTRUCTIONS/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". r,"4 fr;;eal: E)epawtmgiau ,-m,ietinn of item numbeL 3. NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETUR11 TO THE(DAVIE COUidTY HEALTH DEPARTMENT,P.O. BOX &65- (MOCKSVILLE, N.C. 27028) DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM LOCATION OF PROPERTY: �y�� ��,v,-a�Q 14x =3 k Lct U/� Cat7�'wtrtc� Jr \ DATE RECEIVED (office use only) 'es n_o+ (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 certify that I have consent from 'B R. I C O Lo ,owner to 0 1:1owner'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 _1 I 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. I �, DATE SIGNAT (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: DAT E SIGNATITRA 0 Owner Only rj Owner's designated representative Q Anyone requesting results y� Only those listed below a22'la.0 z 4/�C.� APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksvilie, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone f qg' boa I 1. Permit Requested By _�el A) 4 Ig- N e ed Business Phone 79.r 09'50 2. Address / �� kVeO h e,U S D eN 4J OAA) e Al, a 7000 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 6 i^eeO LD0J i#`e'�Sec.,�— Lot No. 5. System used to serve what type facility: House I/ Mobile Home Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions %&t6 `� Gr 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 a urinals garbage disposal lavatory showers a washing machine dishwasher / sinks 8. a) Type water supply. Public_ Private Community b) Has the water supply system been approved? Yesy No 9. a) Property Dimensions 13_S A a8 7 A _5o Xaa O b) Land area designated to building site 7 © X -410 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 cor ect to the best of my knowledge. Date Owner 6ignature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: OCHO (6.62) ' APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 1. Permit 2. Addres 3. Properi Addres CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 4. Permit To: a) Install ✓Alter Repair b) Privy Conventional ✓ Other Type Ground Absorption `� c) Sub -Division -ee-N i.1,ykha � Sec._— Lot No.11210 CA � 5 5. System used to serve wha type facility: House ' Mobile Home Business IndustryOther _. b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 3 L: X -le © Bed Rooms 3 Bath Rooms 2 Den w/Closet_ b) If Business, Industry or Other, State: Number of persons served %Grit What type business, etc. 11 A' Estimate amount of waste daily (24 hours) ff4 7. Number and type of water -using fixtures commodes a - lavatory .2 dishwasher urinals Q showers sinks garbage disposal washing machine 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes—V No �pJ 9. a) Property Dimensions Fri 3 4' Z • 14;0 2 5'�2' b) Land area designated to building site`��� c) Sewage Disposal Contractor I? 10. Do you anticipate any additions orexpansionsof the facility this sewage system is intended to serve? What type? This is to certify that the information is correct the best of my knowled h � s 2�— Date Owner Si nature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: Ttw �� Bn OhA WOJt� DCHD (6-82) j r• r` p aiiie V LtUTT �1 �-IcfTl#I� CjJtT�t1tZL'lT 2TTT1b '-fiville 34cal#Il (�gcllruu P. O. BOX n7 fi65 'Alacksllillc, liartfi (Ilnralintc 27028 OFFICE OF THE DIRECTOR nrtnher 25, 1QR2 Mrs Hazel. Armstronn P.n. Rox 762 Rnrml.iria R! in Advance, N.C. 27nn6 Re! I-nt 0 14. rret-manori I_nkAs nakl,lond Drive Mrs. Armst.rnnn: The ahnvP mnnti.nnpri nrnner. tv h?ri an on—si.te ,^.eI lane, tr. Patment and di-7nnsal. system i.nstal., nH on 5nntnmhnr 25, 1 QR2. Rn thpt same data a renre^Pntativlp, frnm f..hi. nffir.P ann^nvPd the instal�at;.nn and issiled a rprtifinatP of rmmnlPt.inn. Shnul ri vnu have any nuBst.i.n^r rnnrPrni nn this mil -,tar, ^I_easR fPel. frPP to 7nntart this office, 4�-nrPrPly, ,nP ndo. Envir.nnmental Hnnith Conrdinatnr nay.iP County Health Cennrtment TELEPHONE 704/ 634-5985