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179 Whitehead Drive Lot 11DAVIE COUNTY HEALTH DEPARTMENT - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOTE: Issued in Compliance With Article II of G.S. Chapter 130a ._.Sanitary Sewage Systems Permit Number Name — Date N4 Location Subdivision Name Lot No. Sec. or Block No. Lot Size ' House Mobile Home — Business Speculation No. Bedrooms e� .No. Baths No. in Family _ Garbage Disposal YES ❑ NO E] Specifications for System: Auto Dish Washer YES ❑ NO ❑ ,. _ Auto Wash Machine YES E] NO ❑ 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 Diagram: System Installed by r ' this cer set forth for any given period of time. in compliance with r system will function 6. If business, industry, place of public assembly, other: No. of People Served No. of Commodes No. of Lavatories Specify type No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures _ 7. Type of water supply: PR Public ❑ Private 8. Property Dimensions K 2°O X /9d>< //.3K ZSL Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If ves, what tvoe? C5 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: �[_ -Lj.O ( U e, l �-o Ifw1 JFO I , (7N� �d/ S �O �✓ hegs 'J'A -r ✓.+alcC . ! VA.A1 LES o,J UJ PRss /lam. / Jv.L,J � 2 � /(�161� [ O.J (i%r'h7 17 2 • �.0� �// l J ! Jr 0,4) /ztGif> �woa7�ET)� . This is to certify that the information provided is correct to the best of my incurred from this application. DATE understand I am responsible for all charges CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 23-4. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the DavieC my Health Depp�{ttment to enter upon above described property located in Davie County and owned by G'%�2L i3 +c� 1E /w S to conduct all testing procedures as necessary to determine said site's suitability r a bnd absorption sewage treatment and disposal system. DATE / /7 SIGNATHRXI DCHD (12.90) 'APPLICATION FOR SITE EVALUATION/IMPROVEMITS'PERMIT P f f Davie County Health Department U� ' 9 1 a 6 Environmental Health Section a P. O. Box 665 Mocksville, NC 27028���� n ,{ 1{ r L c.; DET ,i 1. Application/Permit Requested By JET •BRAY Mailing Address D L�oX S/`fZ LrJ-rJ .<!G y7//3 Home Phone i/gam 765- �j¢/ S Business Phone 9W' 746 2. Name on Permit if Different than Above ZZ6.7- 3. Application/Permit for:� PKGeneral Evaluation ❑ Septic Tank Installation 4. System to Serve: CI'House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑—Other ❑ Unknown 5. If house, mobile home: / - Subdivision �RE9"WeVD 5 Section 2 Lot # n Mkry E-8-? P^4cE7_ Afz ❑ Basement/Plumbing No. of People 4 ❑ Basement/No Plumbing No. of Bedrooms 0 �4 _? h �ah� ❑ Washing Machine No. of Bathrooms ❑ Dishwasher Dwelling Dimensions 2300 S4 rl-• ❑ Garbage Disposal 6. If business, industry, place of public assembly, other: No. of People Served No. of Commodes No. of Lavatories Specify type No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures _ 7. Type of water supply: PR Public ❑ Private 8. Property Dimensions K 2°O X /9d>< //.3K ZSL Sewage Disposal Contractor 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes If ves, what tvoe? C5 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: �[_ -Lj.O ( U e, l �-o Ifw1 JFO I , (7N� �d/ S �O �✓ hegs 'J'A -r ✓.+alcC . ! VA.A1 LES o,J UJ PRss /lam. / Jv.L,J � 2 � /(�161� [ O.J (i%r'h7 17 2 • �.0� �// l J ! Jr 0,4) /ztGif> �woa7�ET)� . This is to certify that the information provided is correct to the best of my incurred from this application. DATE understand I am responsible for all charges CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: ❑ 1. 1 OWN the property. 23-4. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the DavieC my Health Depp�{ttment to enter upon above described property located in Davie County and owned by G'%�2L i3 +c� 1E /w S to conduct all testing procedures as necessary to determine said site's suitability r a bnd absorption sewage treatment and disposal system. DATE / /7 SIGNATHRXI DCHD (12.90) a 1 p fl Y y.. � j II l � X�i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section Soil/Site Evaluation NAME �I �� / P, DATE EVALUATED ADDRESS PROPERTY SIZE PROPOSED FACIILTY LOCATION OF SITE Water Supply: On -Site Well Community Public E/ Evaluation By: Auger Boring Pit Cut FACTORS 1 2 3 1 4 5 Landscape position t G s Slope % HORIZON I DEPTH Texture group Consistence Structure { d Mineralogy HORIZON II DEPTH 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 j LONG-TERM ACCEPTANCE RATE SITE CLASSIFICATION: _� EVALUATED BY: �L7/,4 Z LONG-TERM ACCEPTANCE RATE: REMARKS: DCHD (01-90) OTHER(S) PRESENT: 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 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 Dam? Caunty NealtFr Dyariment and Noire Xealtfr- . 4yency 210 HOSPITAL STREET/ P.O. BOK 665 MOCKSVILLE. N.C. 27028 PHONE: (704) 634-5985 October 28, 1992 Jeffrey L. Dray P. O. Box 5142 Winston—Salem, NC 27113 Re: Site Evaluation Greenwood Lakes/Sec. 2—Lot 11 Dear Mr. Dray: As requested, a representative from this office visited the aforementioned site on October 23, 1992. 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, Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd Enclosure Phone: (336) - 753 - 6780 Davie County Health Department nviromnental Health Section C P.O. Box 84.8 210 Hospital Street Cowier #: 09-40-06 Mocksville, NC 27028 ON-SITE WASTEWATER CERTIFICATION (Check One) Replacement Remodeling Reconnection Fac (336) - 753-1680 NameGA-Alf [;OZ W Phone Number' -O < < abS� (Home) Mailing Address: Oq ial%!f IPW4ZO t)0-10�:_ (work) "fl:�o7 fllfirt''fAl— CC?���O QLeal 7 Detailed Directions To Site: O✓U Owl 1 4. iyW 4(t.- �. i u Ok %I 0, L)Kd'N'/a'SS Q 1� d✓1 tai k.t'w Property Addre Please Fill In The Following Information About The EEX--ISTING Facility: Name System Installed Under: EjX6 f ( bLC� Y Type Of Facility: Date System Installed (Month/Date/Year): 115 C "1 Number Of Bedrooms: Number Of People: - - - - Is The Facility Currently Vacant? Yes No If Yes, For How Long? - Any Known Problems? Yes No If Yes, Please Fill In The Following Information About The NEW Facility: Type Of Facility: Number Of Bedrooms: Number of People Pool Requ For Environmental Health Office Use Only Approved Disapproved , Environmental Health Specialist �:� /- Date: � —-Fe -7 to *The signing of this fonn 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. Cash Check Money Order Paid By: - Received By: Account #: � 17 Invoice #: %)� -&04L Vll �.y v... mt, oP,�`F 4 E oU�� s Printed:Sep 19, 2016 All data is provided as is without warranty or guarantee of any kind either expressed or implied including but not limited to the implied warranties of merchantability or fitness for a particular use. 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