324 Oakland Avenue Lot 112,. DAVIE COUNTY HEALTH DEPARTMENT o
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-
`— Date - l o = r
Name L`� N2
4 ,P S 1 - s >�,�
-.Location b ti 41 � � S �Jp► � t � N �Z :a.
Subdivision Name � 'w cj Lot No. Sec. or Block No.
Lot- Size Q, Jk?�House Mobile Home _ B siness,u 'Speculation
No. Bedrooms a No., Baths No. in Family,-:,,
C AY
+ GarbageDisposal YES _ NOi Specifications for System:
Auto Dish Washer ,, YES" N0 O o o - - � _
�. r
Auto Wash Machine YES NO i] t!
Type Water Sup ply
"This permif Void if sewage system described`ibelow is not installed, within 36 months from date of issue.
-4
Improvements permit by � \ ZVI
"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 ben installed •in compliance, wi h
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 rC `
Environmental Health Section o
P. O. Box 665 Q�
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
0
Home Phone /-7oh�-�9�- 7�a9
1. Permit Requested By 6Sx/ Z�-�� �ic.�rd0 d-r�� Business Phone
2. Address QT#/ max 99-/ !/7iarX5* 11-4-E ZC 7::27Qo2C
3. Property Owner if Different than Above A/0PE,8'ep —we -',4Z S ' 7?(Z.IA n c 2s iNC,
Address 11A0
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division 6494,41-T Sec. 02 Lot No.ZZ 2-
5. System used to serve what type faciIityf,House Mobile Homes/ Business
Industry Other
b) Number of people 3 "
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions— ��c A.AL
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 2 urinals garbage disposal
lavatory 'Y showers ?i washing machine—
dishwasher sinks f
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
' 9. a) Property Dimensions 7 i< 26 41, fr k It. .S X d 0 6
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? Gif 6
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner STnature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82)
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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
04a e—rV - / /-� (office use only)
Ide
yes no 1. 1 am the owner of the above described property.
yes Cr5o 2. 1 am not the owner of the above described property, however, I certify that I
have consent from/off 6vi,< a 5 /O�c , 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.
ee� 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.
%1/�- 64�
DATE SIGNA U
DCHD (11 /84)
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
DATE SIGNATURE
- DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
Q. SOIL/SITE EVALUATION
Name e S\ \ \� \ (�� Date n " 1 • �,�
Address Q`Lot Size
FACTORS AREW 1 ) ARE AREA 3 l AREA 4
4
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Topography/ Landscape Position
S
PSS
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!) Soil Texture (12-36 in.) Sandy,c
Loamy, Clayey, (note 2 :1 y)
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} PS
PS
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PS
U
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1) Soil Structure (12-36 in.)�
Clayey Soils
PS
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S
PS
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PS
U
U
U
U
Soil Depth (inches)
PS
S
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PS
U
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Soil Drainage: Internal
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PS
U
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External
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_ S
S
PS
-
U
U
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1) Restrictive Horizons
Available Space
Ps
PSPS
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PS
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PS
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1) Other (Specify)
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pg
S
PS
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PS
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PS
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1) Site Classification
S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title�Date y
SITE DIAGRAM
DCHD (6-82)
Davre County Nealtl D7yen artment
and .�lvme .�ealtFrciv
210 HOSPITAL STREET I P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634-5985
October 11, 1988
Leslie Birdsong
Rt. 1, Box 99-1
Mocksville, NC 27028
Re: Site Evaluation
Oakland/Sec. 2 -Lot 112
Dear Mr. Birdsong:
On October 11, 1988, as you requested a representative from this office
visited the above mentioned site. The soil was found provisionally suitable
for the installation of a ground absorption sewage system.
If you have any questions, please feel free to contact this
office.
Sincerely,
Charles E. Little, R.S.
Environmental Health Section
CL/wd
Enclosure