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285 Bridle Lane Lot 4DAVIE COUNTY HEALTH DEPARTMENT 56, cb t �t IMPROVEMENTS PERMIT AND ;CERTIFICATE OF COMPLETION /0.0 *NOTE: issued in Compliance With Article 11 of G.S. Chapter 130a Sanitary_ Sewage Systems \ ^ Permit Number Name G'"1_� C� d 5 — Date L AL3 y y N2 1 8 LocationpSv�Ce"� �c�U�.r�c� ��i•C.—'1�pr��. ` w Subdivision Name ��� � ��' � ISE'� . ...... Lot No. Sec. or Block No. f' Lot Size 5 House Mobile Home __ Business -- Industry No. Bedrooms Z—.No. Baths _ No. in Family Public Assembly Other Garbage Disposal YES ❑ NO ❑ Specifications for System: Auto ish Washer YES ❑ NO ❑/poa ��� \� , Auto W sh Ma thine YES [d( NO ❑ Type !Nater Supply — �)) :�` X �, 1A� *Thisermit Void if sewage system described below is not installed within 5 years from date of issue. This ermit is subject to revocation if site plans or the intended use change. Fin Improvements permit by Cal s �, *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. Certificate of Completion \ "� e Date3 '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. L u f Improvements permit by Cal s �, *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. Certificate of Completion \ "� e Date3 '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. No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers _ No. of Showers Water Usage Figures _ 7. Type of water supply: ❑ Public ® Private 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is Intended to serve? ❑ Yes If vac what fvna9 No ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: G / 169-5 if 140t15 -e_ 14111 /- b� V This is to certify that the information provided is correct to the be t of my Incurred from this application. DATE and I understand I am responsible for all charges SIGNATURE CONSENT EQB IN EVALUATION IQ BE DONE QN ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 QWN the property. l& 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MAM be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davieounty Health Department to enter upon above described property located in Davie County and owned by _,Ty / zil v row q`S to conduct all testing procedures as necessary to determine said site' suitability absorption sewage treatment and disposal system. DATE // SIGNATUF3F/ DCHD (12.00) ilk, APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT _ Davie County -Health Department Environmental Health Section '1 ������® e'1 P. 0.. Box 66 Mocksville, NC 27028 OCT ! l S94 1. Application/Permit Requested B"yZA-e"1 <7 h Mailing Address 53 Home Phone WZ kyr e1 Business Phone 2. Name on Permit if Different than Above 5�E> �. %USI S� d 3. Application/Permit for: EMeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: ❑ House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision �� 54 rnn A # - Section -.lam Lot # ❑ Basement/Plumbing No. of People ❑ Basement/No Plumbing No. of Bedrooms 53,'Washing Machine I �� No. of Bathrooms ❑ Dishwasher Dwelling Dimensions ❑ Garbage Disposal 6. If business, industry, place of public assembly, 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 Water Usage Figures _ 7. Type of water supply: ❑ Public ® Private 8. Property Dimensions Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is Intended to serve? ❑ Yes If vac what fvna9 No ❑ Community 'NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: G / 169-5 if 140t15 -e_ 14111 /- b� V This is to certify that the information provided is correct to the be t of my Incurred from this application. DATE and I understand I am responsible for all charges SIGNATURE CONSENT EQB IN EVALUATION IQ BE DONE QN ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 QWN the property. l& 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MAM be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davieounty Health Department to enter upon above described property located in Davie County and owned by _,Ty / zil v row q`S to conduct all testing procedures as necessary to determine said site' suitability absorption sewage treatment and disposal system. DATE // SIGNATUF3F/ DCHD (12.00) G / 169-5 if 140t15 -e_ 14111 /- b� V This is to certify that the information provided is correct to the be t of my Incurred from this application. DATE and I understand I am responsible for all charges SIGNATURE CONSENT EQB IN EVALUATION IQ BE DONE QN ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 QWN the property. l& 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MAM be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davieounty Health Department to enter upon above described property located in Davie County and owned by _,Ty / zil v row q`S to conduct all testing procedures as necessary to determine said site' suitability absorption sewage treatment and disposal system. DATE // SIGNATUF3F/ DCHD (12.00) DAVIE COUNTY HEALTH DEPARTMENT Environmental' Health Section Soil/Site Evaluation NAME . ` `�'`/, DATE EVALUATED ADDRESS ` PROPERTY SIZE�_�/ / / PROPOSED FACIILTY NL Zf LOCATION OF SITE -�'�% d��j,.- Water Supply: On -Site Well Community Evaluation By: Auger Boring Pit FACTORS 1 2 3 4 Landscape position Slope Z — -- HORIZON I DEPTH Texture group Consistence Structure Mineralogy HORIZON II DEPTH f" Texture group Consistence Structure 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 R.ATEJjr Public Cut SITE CLASSIFICATION:y� EVALUATED BY: LONG-TERM ACCEPTANCE RATE: f 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 -Firm 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 5C -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 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 Davie County Yleall Deparhnent and .Mame Nealt§ Ayenq 210 HOSPITAL STREET/ P.O. BOX 665 MOCKSVILLE. N.C. 27028 PHONE: (704) 634-5985 October 13, 1994 Scott L. Lindsey c/o Gray A. Potts 5342 Hwy. 158 Suite #1 Advance, NC 27006 Re: Site Evaluation Rabbit Farm/Sec. 1—Lot 4 Dear Mr. Lindsey: As requested, a representative from this office visited the aforementioned site on October 12, 1994. Based upon the information provided on the application for a site evaluation and after the evaluation was completed, the site was found to be provisionally suitable for the installation of an on—site sewage disposal 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 e - _�C,C/'�edI C � - /IA31gI HEALTH DEPARTMENT RELEASE For Office Use Only *CDPFiIeNumber 187545-1 Davie County Health Department G7-000-00-139-14 210 Hospital Street County ID Number: P.O. Box 848 �Evaluated For: HDR/WWC Mocksville INC 27028 1 -,- Phone: 336-753-6780 Fax: 336-753-1680 PERMIT VAUD 0 1 / 0 9 / a 0 a 0 UNTIL: — — Applicant: Statesville Pool and Spa Address: 411 S. Center St City: Statesville StatefZip: NC Phone #: /'/P'roperty owner: Christopher and Carolyn Address: 284 Bridle Lane City: Advance StatefZip: NC 27006 ��hone #: (704) 902-7650 Property Location & Site Information Subdivision: Rabbit Farm Phase: Lot: 4 Road# Advance NC 27006 — SINGLE FAMILY Township: *Structure: Directions # of Bedrooms: # of People: Hwy 64 East left on Cornatzer Rd right into Rabbit Farm *Water Supply: PUBLIC Basement: F—]YesF—]No .Proposed Improvement: Pool Type of Business: Total sq- Footage: No. Of Employees: Aease Conditions Approved as drawn on site plan. Keep pool 15'minimum off septic and 25'minimum off well. This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. ApplicarittLegal Reps. Signature Required? OYes ONo Applicant)Legal Reps. Signature, —*Date:— *IssuedBy: *Date of Issue: 0 1 0 9 2 0 1 5 Authorized State Agent: **Site Plan/Drawing attached.** *HandDrawing OlmportDrawing Davie County Health Department Environmental Health Section P.O. Box 848 2 10 Hospital Street ILL— Courier # : 09-40-06 Mocksville, NC 27028 Phone: (336) - 753 - 6780 Fax: (336) - 753-1680 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Name: A61-- Number (Home) Mailing Address: Lill _-S ez..� ;:v- 70+ - 7C 56 _(Work) Paf rw Detailed Directions To Site: 2 - 14a- en 4 N j.,xIAniior A jqi-m A ij, Property Address: on , - - — & 0 6 — 0 0 — I Please Fill In The Following Information About The EXISTING Facility: A 01 Name System Installed Under: _____:rype Of Facility: Pv- Date System Installed (Month/Date/Year): Number Of Bedrooms: Number Of People: Is The Facility Currently Vacant? Yes No Any Known Problems? Yes No If Yes, If Yes, For How Long?. Please Fill In The Following Information About The NEW Facility: _T;_�a Number Of Bedrooms: Number of People Type Of Facility: Pool Size: Garage Size: —Other: Requested By: Date Requested: /* (Signature) For Environmental Health Office Use Only Disapproved Comments: 'V,<s,,tn oA� c, Environmental Health Specialist /�� � III, —jrjAVj I I (k(��kLUk, Date: I h I I q *The signing of this form by the Environmental Heal1v taff is in no way intended, nor should be taken as a guarantee (extended or limited) that the on-site wastewater system will fimction properly for any given period of time. Payment: Cash Q �ec ' Money Order # Arnount:$ 400, 0 e) Date: aW Paid By: Received By: Account #: Invoice #: N 4 - G) on 50,+ 2 0!4 - Poo I " 'I e. app'. -6 0 t V- ,4.p,d dA,, -s; rredeqe- ra---c- lvc_ LAA -t le el