109 Raintree Road Lot 3DAVIE 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) Per'mit Number
Name ,,'�' !;.i: %i:J���i'/✓.�,je� %i r Date N2 5
Location / ✓�r' /_Cr%�' ,%, ii, /f �f —
Subdivision Name %)� ; /'�'
Lot No. , Sec. or Block No. /
Lot Size House / Mobile Home — Business Speculation
No. Bedrooms No. Baths r No. in Family
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES g NO ❑ `Gw�A�`r (c�,.'
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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.
Final Installation Diagram:
System Installed by
i i
Certificate of Completion—4.1-114,-"'11/ 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.
P 0.0
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
5 14 : Davie County Health Department
Q I QAq v� Environmental Health Section
I� P. O. Box 665
7� Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Reque ed By ��—iz /�f� t -d Business Phone
2. Address %_ —� �a C�/Csy , jG�_ c`6 , IP -7 d Z F
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ter Repair
b) Privy Conventional her Type
Ground Absorption
c) Sub -Division. Sec. f 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 o home and number of rooms.
House Dimensions 24:� OD
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 3 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public 4—� Private Community
b) Has the water supply system been approved? Yes o
9. a) Property Dimensions `g (9>:� _e�av
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 best of my knowledge.
���
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
A-1111-9
Address
FAr'.TORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 1 ARFA 9
Date
Lot Size Zyd� 1%
AREA 3 AREA d
1) Topography/ Landscape Position
4)
5)
6)
8)
9)
r
S
S
Address
FAr'.TORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 1 ARFA 9
Date
Lot Size Zyd� 1%
AREA 3 AREA d
1) Topography/ Landscape Position
4)
5)
6)
8)
9)
S
S
S
S
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
Soil Drainage: Internal
S
S
S
PSS
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
Restrictive Horizons
Available Spaces
S
S
S
g
PS
PS
PS
U
U
U
U
Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE / S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: `
Described by
�=1' Title L�l Date
���
SITE DIAGRAM
DCHD (6-82)
• DaiYe County Nealtfr De artment
and .dome Neak Aen
9 cy
21 O HOSPITAL STREET / P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE: (704) 634-5985
June 6, 1988
Potts Realty
P. 0. Box 11
Advance, NC 27006
Re: Site Evaluation
Raintree-Sec. 1, Lot 3
Richard Short
Dear Realtor:
On May 27, 1988, as you requested a representative from this office
visited your site and found the soil 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
RH/wd
Enclosure
Davie County Health Department
9 6j Emgronmenud Health Section
-:
< �`
P.O. BOX 848
'S' RECEIVED 210 Hospital Street
C
`m+ L, �z
Courier #: 09-40-06,
C? tI
Date: Ity I\Iocksville, NC 27028
Phone: (336) - 753 - 6780
Fax: (336) - 753-1680
ON-SITE WASTEWATER CERTIFICATION
(Check One) Replacementemodelin Reconnection
Name: e15ci ill _ Phone Number
(Home)
Mailing Address: }? O, �5c+> ; (.5 z .'7 36: _ 75-7-2
Si (Work)
ADv,4i��A1 C 21c(%G
Detailed Directions To Site: Z u_) tj ftp r;+ -S ! , A- 16,V —7- r,,lt% M-c%L4
Property Address:.
Jr+ K.E�
Please Fill In The Following Information About The EXISTING Facility:
Name System Installed Under: �1 C�%1;��- Q1% Type Of Facility: E
Date System Installed (Month/Date/Year): l/" ly�_Number Of Bedrooms: Nutter Of People: Z
Is The Facility Currently Vacant? Yes 6o! If Yes, For How Long?
Any Known Problems? Yes Nod Tf Yes, Explain:
Please Fill In The
�Following
/�Information About The NEW Facility: r
Type OfFacility: �k09", {' 9AMe001;4 Number Of Bedrooms: Number of People
Pool Size: Garage Size: Other:
Requested By: Date Requested:
(Signature)
For Environmental Health Office Use Only
Approve Disapproved
cove Noremodelmo G1� f
� Dri�In��S�ru�
Environmental Health Specialist��� t-� Date:
*The signing of this form by the Environmental Health Staff is in no way intended, nor should be taken as a guarantee
(extended or limited) that the on-site wastewater system will function properly for any given period of time.
Payment: Cash Check Money Order #' Amount:S_
Paid By: Received Ry:_
Account #: Invoice #:
,