118 McDaniel Road Lot 5CGS
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)
Name 5 _ y, i 2 j�� — l > -_ 1, Date 1/1
Location
Permit Number
O fi)u
Subdivision Name Lot No. - Sec. or Block No.
Lot Size ���''I %" G House Mobile Home _ Business Speculation
No. Bedrooms-~ No. Baths No. in Family rV _
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO El
YES [ti NO 0
YES NO p
Specifications for System:
sir o
"This permit Void if sewage system described below i not intalled within 36 months from date of issue.
r'
Improvements permit by Z Zl Z/
'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
Certificate of Completion �'
� Date ,L
'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 M~V M
Environmental Health Section R�r,
P. O. Box 665
Mocksville, N.C. 27028
;1!�N&RUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
((��
n Home Phone 7 5S t/ / 5
1. Permit Requested By 0306by 0 Business Phone 7q5- 3 S Va
2. Address _W5,SS [M�.:WT4 L— Ra VL' v) 0—In– S-11", 1UL 2"-7/0�2
3. Property Owner if Different than Above
Address
4.. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption Qiac�U�
c) Sub -Division Se Lot No. ((��
5. System used to serve what 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_0 0 5!� H—
Bed Rooms 3 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 urinals D garbage disposal n
lavatory showers 2- washing machine
dishwasher sinks 3
8. a) Type water supply: PublicPrivate Community
b) Has the water supply system been approved? Yes VNo
9. a) Property Dimensions -- a 00 F+ Y\ YOD F -4-
b) Land area designated to building site
c) Sewage Disposal Contractor iR i c k v�
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? M0
What type?
This is to certify that the information is correct to the best of my knowledge.
5-3 _ql�
Date
Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Cpl TO COrticlt cr 7v 62a
s•t- Go, -t— o vl �- � 5 j�-T—
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: 1 r' f or o n R,::)6r- DATE RECEIVED
o ) C\J.0—r] (office use only)
ISG �I1 C( n �c94(/f C�Vip u IWS
no 1. 1 am the owner of the above described property.
yes 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.
0ye 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
0�
DATE SIGNATURE
DCHD (11 /84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
NameDate
Address Lot Size 'a,j6 ,Y �%»
4
c
For:TORR ARFA 1 AREA 2 AREA 3 AREA d
1) Topography/ Landscape Position
S
S
S
P
)
(
PS
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
S
S) Soil Structure (12-36 in.)
S
Clayey Soils
S
S
l) Soil Depth (inches)
P
P
P
S
U
U
i) Soil Drainage: Internal
S
S
S
P
P
�
P
U
U
jj
External
S
S
S
P
P 3
P
U
U
U
i) Restrictive Horizons
Available Space
S
P
F S
S
PS
S
U
1) Other (Specify)S
S
S
PS
S
U
U
U
i) Site Classification
��S'
��-P
I/, (
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: .0 !Z
Described by y?!�Title ��'��" Date
SITE DIAGRAM
DCHD (6-82)
•
•
STATE OF STATC OF
R�AIfY ':•Y '4C
�. T7 ,, CxC�SITXIt ". : ;.:1 �. ! 4xC::•�\ t...x
S I O.00 f i "!:!.00
Excise Tax TA:( aU.'..RYiSOR
00,
DM =KCff—PAGalj /
r " KW PCOnPrRAT1p1
May 9, 1989 4:05 P.M.
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a+o tsceam N soon 1ALPAOg.riii
NIM L stone aER .. Go taaas .
oavi wurtv. ILC
• er wie. �. o!-tf��A�'
'Assistant
Recording Time, Book and Page
Tax Lot No. ..... Parcel Identifier No . ..... :..........................................................
Verifiedby ............. ......................................... ....:............. County on the ............... day of ......................................................... 19............
by.....:........:..........................................:.......................................%.................................................. ,.................,,......................... ...................
.......
Mail after recording to .....Bobby,.Dale„Moser..G 655•,Meriweather Road,„Winston-Salem, NC 27107
............................................................................................................................................................ ... ................
Geor e W Martin. Attorne at Law. M9cksville. NC 27028
This instrument was prepared by.......................8.......•.............................. ....i' .
Brief description for the Index
Th. Poplars
NORTH CAROLINAGENERAL WARRANTY DEED
THIS.DEED made this ...5t#l...... day of.............gay..............................:........... 19. $9...., by and between
:,GRANTOR
1
POTTS REAL ESTATE, INC.
GRANTEE
BOBBY DALE MOSER and
LEANN ANNETTE CLINE
t
,inter In approprlate block for each party: name, address, sad. It appropriate, character of entity, e.4 corporation or partaershlp.
The designation Grantor and Grantee as used herein shall include said parties, their heirs, successors, and assigns, and
shall Include singular, plural, masculine, feminine or neuter as required by context. !
WITNESSETH, that the Grantor, for a valuable consideration paid by the Grantee, the receipt of which Is hereby
acknowledged, has and by these presents does grant, bargain, sell and convey unto the Grantee In fee simple, all that
curtain lot or parcel of land situated in the City of.:.............:..............I...,..........:.......... ,.............................................. Township,
. .................... Pavia............. County, North Carolina and more particularly described as follows: 1
BEING I010101 and designated as Lot 5 of *THE POPLARS* Subdivision as the
same appears on a plat thereof rworded in Map.Book 5, page 132, Davie
County Registry to which referetlos is mads for amore particWar
description.
N. C. an Arne. Fwn. No. 7 O 1171. R«YN 0.1177 -a... e.nw.a pr Ma, M. tai, r.*r..� w e. r/*s
nnx.e.r M...rr wN. NI.R C.MArK-INI
DAVIE COUNTY HEALTH DEPARTMENTc�1
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Rn, Po }}s Date g ' 1-4 - $�
Address Lot Size 7 -on X 400
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)PS
>
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
�
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
U
) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
') Available Space
S
S
S
S
PS
PS
PS
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
;) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suita
Recommendations/ Comments:
Described by S -rXNN ,—,, Titlekk� C"- Date g- 14 "
SITE DIAGRAM 7001
401
DCHD (6-82)
w
Davie County Jfealtl De ariment
and Name Aealili Ayency
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634.5985
April 14, 1989
Mr. Roy Potts
P. 0. Box 11
Advance, NC, 27006
Re: The Poplars/Lot #5
Dear Mr. Potts:
Please find enclosed a copy of the site evaluation conducted by this
office in 1985 on Lot #5, The Poplars. As you can see, this site was
classified as provisionally suitable and this classification would remain
unless conditions have been altered at the site.
Before we can issue an Improvement's Permit, we must have an application
requesting a permit for Lot #5. At that point our staff would visit the
property and determine the size and location for the sewage disposal system.
-Please advise should you have any questions.
Sincerely,
9
oe Mando, R.S.
Director of Environmental Health
JM/wd
Enclosure
Y