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DA IE COUNTY HEALTH DEPARTMENT
E IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:`Issued in Compliance With AyqclptlpJ,P.S.C�ter 130a
% �� ., Permit -MMT
--Sanitary Sewage Systems , , � � II
" f3
Name D t No
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size, House Mobile Home `— Business -- Speculation
No. Bedrooms .No. Baths — No. in Family J —
Garbage Disposal YES ❑ NO ❑ Specifications. fqr-System:
Auto Dish Washer YES C] NO
❑ /<%4%'� `r l
Auto Wash Ma.hine YES ❑ NO ❑ ��-it'-/e';j%�:y
Type Water Supply __—
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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 Dia
Svctam Installed by —
dy
Sf
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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section RECEIVED FEB $
19
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPRO�MENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Re ested QACI Business Phone q -
2. Address 70. S-6 �R-
3. Property Owner if Different than Above fl \ t `,
Address
4. Permit To: a) Install ✓Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec Lot No.
5. System used to serve what type facility: House Mobile Home— Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 a urinals garbage disposal
lavatory showers washing machine
dishwasher sinks %
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions 1 Z�5 �\ _"_Q
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 SigrPature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
O_L� I
ljqlql
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
LOCA ION OF PROPERTY: DATE RECEIVED
(office use only)
yes no 1. I am the owner of the above described property.
yesT01)2. 1 am not the owner of the above de abed property, however, I certify that I
have consent from 9�-->)S V 0 's , 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.
F
no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Departmentto 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: .
0 ner only
-Owners designated representative
Anyone requesting results
Only those listed below
V�, 6Z:j - P" P. o, P"
DATE IGNATURE
DCHD (11 /84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
Soil/Site Evaluation
NAME �/ ![ / /�/i DATE EVALUATED
ADDRESS PROPERTY SIZE
PROPOSED FACIILTY on�y LOCATION OF SITEDC��,IC. /
Water Supply: On -Site Well Community Public
Evaluation By: Auger Boring Pit Cut
FACTORS
1
2 3 4
Landscape position
Sloe %
112-
-12-
HORIZON I DEPTH
Texture group
Consistence
Structure
Mineralogy
HORIZON II DEPTH
Texture group
Consistence
Structure
i
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 RATE
SITE CLASSIFICATION: >6_r" EVALUATED BY: /7/5
LONG-TERM ACCEPTANCE RATE:y _/
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
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
SC -Single grain M -Massive CR -Crumb GR -Granular ABK-Angular blocky
SBK-Subangular blocky PL -Platy PR -Prismatic
Mineraloz►
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
■
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■ONOMME■■■■■
1 ` '
Davie County Jleabii De artment
F and .dome NealtFr Myency
210 HOSPITAL STREET/ P.O. BOX 665
MOCKSVILLE. N.C. 27028
PHONE: (704) 634.5985
February 28, 1991
Betty Potts Realty
P. 0. Box 2056
Advance, HC 27006
Re: Site Evaluation
Hattie & Ethel Jones - Owners
Thomas G. & Deborah B. Pullen, IV - Buyers
Beauchamp Road
Dear Realtor:
As requested, a representative from this office visited the aforementioned
site on February 27, 1991. The site 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,
A 4 t 44f; ; � �S� 'e- ' �
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd
Enclosure
rDavre Cvunty .�ealiir'De ar�merrl
t 7
and ,�fvme .7feal Fy cy
210 HOSPITAL STREET P.O. BOX 665
MOCKSVILLE, N.C, 27028
PHONEI (704) 634.5985
April 29, 1991
Thomas G. Pullen, IV
c/o Betty Potts Realty
P. 0. Box 2056
Advance, NC 27006
Re: Site Evaluation
Thomas G. b Debbie B. Pullen, IV
Beauchamp Road - 10 acre tract
Dear Mr. Pullen:
This letter is in regard to a 10 acre tract of land located on Beauchamp
Road in Davie County. On February 27, 1991, this office classified said site
provisionally suitable for.a ground absorption sewage system. Any areas other
than draws and drainways are provisionally suitable in the open plowed field.
Sincerely yours,
Robert B. Hall, Jr., R.S.
Environmental Health Section
RH/wd