158 Raintree Road Lot 24DAVIE "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-.196) ,j Permit Number
Name " /',�.�r Date ���d' ® 4970
Location
Subdivision Name yam`% V,4, Lot No. _ Sec. or Block No.
Lot Size House. Mobile Home — Business- Speculation
No. Bedrooms No. Baths �� No. in Family
Garbage Disposal YES ❑ NO
Specifications f r yste
Auto Dish Washer YES NO fl .d�>
Auto Wash Machine, YES �] NO ❑56
Type Water Supply
'This permit Void if sewage syst described below is. not installed within 36 months from date of issue.
,--�
Improvements permit y
I Y
'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
The sigriing of this certificate shall indicate I 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
"b 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) Permit Number
Name - — Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ _ Business __ Speculation
No. Bedrooms No. Baths _ — No. in Family _
Garbage Disposal YES ❑ NO ,E]- Specifications for, System:
Auto Dish Washer YES p NO ❑
Auto Wash Machine YES] NO ❑
Type Water Supply
-'r
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
'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
'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.
�y J
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksvilte, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
f `A' Home PhoneL%117) 766-11757
1. Permit Requested By L-wyri �V' ���P�e��S Business Phone(`?igI) 7ZZ- 7%0
2. Address 3Z2-0 VJ:i\owocr( ti C- C.lexv utn's b k� C- ? ?c (-Z_
3. Property Owner if Different than Above :J Nt►IEs- 4212
Address ej. 3- Be 41 A b V14 lye, v
4. Permit To:Install Alter Repair—
b)
epair b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: HouseX Mobile Home Business
IndustryOther
b) Number of people 4
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Sa x 3o R,
Y
Bed Rooms_ Bath Rooms 2 Y2 Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc
Estimate amount of waste daily (24 hou
7. Number and type of water -using fixtures:
commodes 3►- urinals garbage disposal
lavatory '4' ! tgn showers 2 washing machine
dishwasher I sinks 2- Sid% �� 54-Q
8. a) Type water supply: Public X Private Community
b) Has the water supply system been approved? Yes X No
'a) Property Dimensions X 5ct do _
b) Land area designated to building site 0-/,a 211•►.?^�1'"��; G-Nt4 = 74 0" X
c) Sewage Disposal Contractor 4-0 be-
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.
�6 ,
Date Owner Sig ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LCAL LAWS
Allow 5 days for processing
Directions to property:
Ga -to ccrACV-
9(c) _ zy
1
4
Al
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. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
G+24-1-:-,1 (office use only)
yes ono 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 ao mcs A. Sor i my r , 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.
9 23 bis
HC,4 y
ATE GNA RE
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
X Only those listed below
9/2 s /A�
'DAYE
DCHD (11 /84)
ZLrr
SIG TUR
p ,
U
•12 13335 7r?9'10
37971
A V dk N O y N• Z
m _
1,�•� Zhu O °1 � $ N �' `! � �+ K $ Z
z m
to to pj
bf; S� ;
�bl
P�efF vvn�,� sal✓GERv ��•�° '
M�rrr8u✓1 Alt-li .
1
' 's, --s C.5•14
ROAJ)
�a
oo
m
o° 6
no, 103,59 � 1�� ►S �� ?
co 19 i
4n 15
AO N ts4 r o o
/� h h
�7 1 g N
W •
POJ
.►
stir 55.59'E 36.32
a r CS 60.4d' 47'E 21.35
' 1
O`.� ► io I HEREST.CERTIF11 THAT Tba
ap k SUPPLY POSAL IISIILEC 0* p%jpQD PO4 MN
TIS SlAsomwN N1 T 1 TL ED:
1
aM ENS OF a •FVllr a
S400W43w NORTH C
1 •i STATE HEALTH O PA#tW*'EMT AMI
Ot1" HEMIY APPMOVEO AS SHp1M .
CJAMU*4 &UE
MINNOW �M
LIMY +ENAT qw. .
dM
AMWT "a
„Ir
Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
) Topography/ Landscape Position
2)
3)
d)
5)
6)
8)
9)
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
Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
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
S
PS
PS
PS
Restrictive Horizons
Available Space
S
S.
S
S2–>
4
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
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABL PS—Provisionally Suitabl