655 Georgia RdHEALTH DEPARTMENT RELEASE
1.� Davie County Health Department
210 Hospital Street
V P.O. Box 848
a Mocksville NC 27028
Phone: 336-753-6780 Fax: 336-753-1680
Applicant:
Jerry W Eller
Address:
2100 Maynard Rd.
City:
Yadkinville
State/Zip:
NC 27055
Phone:
(336) 463-2827
For Office Use Only
*CDP File Number 122438 -1
F2-000-00-038
County ID Number:
,Evaluated For: EXISTING
PERMIT VALID 0 7/ 2 4/ 2 0 1 8
UNTIL:
Property Owner:
Address:
City:
State/Zip:
Phone #:
Property Location & Site Information
Addrdss655 Georgia Road — Subdivision:
Road# Mocksvlle NC 27028
Township:
Directions
601 N to Liberty Church Rd. Turn L onto Bear Creek ch Rd. L onto
.Georgia Road. peoperty is 1 mile on right in front of Milnok Lane.
'Structure:
SINGLE FAMILY
# of Bedrooms: 3
`Water Supply: U'A
Basement: rlYes ❑ No
# of people: 2
'Proposed Improvement:
New Mobile Home to hook to exisiting
t
Phase: Lot
Type of Business:
Total sq. Footage: No. Of Employees:
It is the responsibility of the owner to maintain a S minimum setback between the wastewater system and any partof the structure
foundation, including porches, decks, and any other appurtenances. If you are unsure as to the exact location of the septic system, please
have a licensed installer or inspector locate the septic system for you. The local county health department in no way implies that the
proposed construction meets the required setbacks from the septic system unless otherwise noted. This release only shows that this
property has an approved wastewater system that appears to have met the permitting requirements at the time it was installed.
This release in no way expresses or implies that the existing subsurface sewage treatment and disposal
system serving the site will continue to function for any period of time.
Applicant/Legal Reps. Signature Required? (DYes (DNo
Applicant/Legal Reps. Signature-, *Date:
*Issued By: 2244 - Daywalt, Andrew *Date of Issue: 0 7 / 2 4 / 2 0 1 3
Authorized State Agent:
**Site Plan/Drawing attached.** Total Time:(HH:MM)
0 1 Hours 0 0 Minutes
O Hand Drawing O ImportDrawing
V1
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Davie County Health Department
Environmental Health Section
P.O. Box 848
210 Hospital Street
Courier #: 09-40-06
Mocksville, NC 27028
'[�CEI�'�'D.
Phone: (336) - 753 - 6780 Fax: (336) - 751 - 8786
ON-SITE WASTEWATER CERTIFICATION FOR DWELLING ('r{`��j
(Check One) Replacement Remodeling Reconnection
Gull C��� .z
Name: Je�/'�f Elly Phone Number 3.36' - /63 —J6ff0 (Home)
Mailing Address: 2 6 40 .3 36 — W S — f"20b (Work)
yaalh. ✓.'l e . At, 19, .2 %DSS" Email l—'ellei- 64P�eCh4s!`.'5 / Kg 0 c Lf A"
Detailed Directions To Site: 0/0/ /yord /a eIVC " 7y irx.rd K , ;rAln 0 to Cr,_ k
ne / na '
-�roa f pic In dnok Lane
Property Address: 6eon5; R Ad. /LLoc�Cs v�'/le Al, C', a27 01ZE
Please Fill In The Following Information. About The EXISTING Facility:
Name System Installed Under: D61 01.12 y Type Of Facility: SLc> /H
Date System Installed (Month/Date/Year): &_F61 Number Of Bedrooms: Number Of People:
Is The Facility Currently Vacant? es If Yes, For How Long? 3 w
Any.Known Problems? Yes (9 If Yes, Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: IT X 6o in.ble ..-v- Number Of Bedrooms:_.�Number of People
Requested By: Date Requested: 7/Z 3
/3
Signature)
For Environmental Health Office Use Only
Approved Disapproved
Comments:
Environmental Health Specialist 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:as heck Money Order # Amount:$ 1/(Date: 7 -,213-13
Paid By: (L -e (/(Y— t'/1 Received By: /* L%&,11 --e,- �{-
Account #: �— Invoice #: /�?3°i T,�j,/t�S �TI`
Ca S h i� a k/QD �s'l tk 12Z Ll 31�
ski 6,
DAVIE COUNTY HEALTH DEPARTMENT Chi /AluJ
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 ❑ Specifications for System:
Auto Dish Washer YES E] NO ❑
Auto Wash Machine YES ❑ NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
r
1
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
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 AII&�
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone���
1. Permit Requested By
CBusiness Phone
2. Address
3. Property Owner if Different than Above
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�usiness
Industry Other
b) Number of people .9
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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
lavatory
urinals
showers
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Y
9. a) Property Dimensions ,���—!
b) Land area designated to building site
c) Sewage Disposal Contractor
No
garbage disposal
washing machine
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 kn wledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Fog
DCHD (6-82)
,i
E
Name—
Address
.K �) V1.Q\
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date Pa 1 ~
Lot Size I S'
ARFA 1 ARRA 9 ARFA3 AREA A
1) Topography/ Landscape Position
\
PS –
S�
SPS ,'
S`
_PS. ,
S
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
SPS_'
S
'PS`_'
S _-
' PS
S
PS
U
U
U.__
U
3) Soil Structure (12-36 in.)
S
-S-,.,
S
Clayey Soils
(rPs"
PS
SPS.-'
PS
U
U
U
U
I) Soil Depth (inches)
S
PS
S
PS
PS
S
PS
U
i) Soil Drainage: Internal
PS
S
PS
S
PS
U
U
U
U
ExternalS
�—�P 0
PS
PS
S
PS
U
U
U
i) Restrictive Horizons
Available Space
�S
C____�
PS
U
U
S
PS
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS' Obvisionally Suitable
Described by Title Date 1c�
SITE DIAGRAM
DCHD (6.82)
Loi Size�;� House t.. Mobilg Home Business Speculafion"'
No Bedroorns r No Bat�is _ No. in Family s
.. •.r ...r r. G. ,...i i .e. '....,.
Garbage Pi8posal. ,OYESa NO j. '
t Sp6cifications for .System:
AUto.DISh Washer r, YESS.N
NcQ-rfl lN'a�. % a
.V
AutoWash-Machine YES';[�r,lIQ�Q 6-11:.`
TYpe, Water Supply: �` ,.✓ l\Ji s .'
rt
*This :permit Void if sewage system described below. is_notrinstalled within 36 months from date of issue.
_w
y
J
. _ `S�� •`.''— C.�.�—_—.ter +rr.«.�,n. ... i .. .,. t .. .
- .,. -,. . -t :,i q �i. i? ., r 1- t. •';.' :-<i:".if _ :.i rl'.. �... .. it` _
.. 1. `. .r , ... � r ..i '.Y i>t�ri`" .5,{ at 1 .v,• r. .. tr 7 y`Y,x , .• ... .. .. .. i;,h,"3.
Improvements permit by *'`=
- 1i,. r ,:,�_ .F-r."vt�: t ., ?i. fr�'r;f�`i., S.=, ,u s.r"a:?. ';,, $',':3 'rt_ii` iE;; �•i".,:316,f+,'+r:
*Contact a representative of the, Dav:e.,'County Health Departme,ot` for -final •inspection 61: this system between, `8-:30L
r
9:30 A.M. -or 1:00 '1;;30=R.M �on--day of. -completion. Telephone,'NO]bbe' 7.04.634.5985 w � y
Final Installation Diagram. System lista fed-byz
Certificate of'Completion Date
*The signing of this certificate shall indicate that the system described above has been installed in ;.complianc
the standards set forth in the above regulation, but shall..in NO; vyay be taken as a guarantee'that the systempill fu
satisfactorily for any given period of time.