P6097 Gordon Dr Civ
DAVIE COUNTY HEALTH DEPARTMENT
�-
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a --_
Sanitary Sewage Sy tems Permit Number
Name�?J c���S–,_ [� c�^cc,` �. � Date ? ,� N2 u
Location
Subdivision Name Lot 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 ❑ NO ❑
Auto Wash Machine YES V NO ❑ f
Type Water Supply
v
*This per 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.
. i
100,0V.
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 � h-fi� 11-rN.�
V" c�
�r- Certificate of Completion Date
Date J `
*The signing of this cer ificate shall indicate that the system described above has been installed in compliance with
the standards set for in the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any givep period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIPto
Davie County Health Department..ei
yAr�
' Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028 )tO
3 �
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Reques ed By Business Phone
2. Address C• 2 7oG
�. 3. Property Owner if Different than Above
Address -
4. Permit To: a) Install Alter Repair '-
b) Privy Conventional Other Type—
Ground
ype Ground Absorption
c) Sub-Division Seca Lot No.
5. System used to serve what type facility: House-LCMobile Home Business
IndustryOther
b) Number of peo
6. ay If house omobile ho , state size of home and number of rooms.
House Dimensionsj Al � 60
Bed Rooms L 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 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private C mmunity
b) Has the water supply system been approved? Ye No
9. a) Property Dimensions
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 Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
444
_—
of
'b
DCHD(6-62) �T 1
F
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
1G o, NA J)lze-�� (office use only)
yesno 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– c�i�-oma � 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.
es no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Departmentto enter upon the above described property and conductall
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:
— Owner only
— Owners designated representative
—Anyone requesting results
— Only those listed below
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name & Date
Address S A CCAQ Lot Size X
FACTORS
A AREQ ARE ARE`A�
1) Topography/Landscape Position SS
PS
2) Soil Texture (12-36 in.) Sandy, —��
Loamy, Clayey, (note 2:1 Clay) C PS 1
U U U U
3) Soil Structure (12-36 in.) S
Clayey Soils % P
U `—W
4) Soil Depth (inches)
vU U
U
5) Soil Drainage: Internal
� U
External S
PS
U U U
6) Restrictive Horizons ----------
7) Available Space SS S
S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U
9) Site Classification S a.J
U—UNSUITABLE S—SUITABLE PS—Provisiona ly Suitable
Recommendations/Comments: � �
Described by Title Dater!
SITE DIAGRAM
19�o
�J
DCHD(6.82)
Davie County �ealtFi yart7nent
.and .dome Neakincy
210 HOSPITAL STREET I P.O.BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634.5985
May 12, 1989
Wayne R. Hamilton
Rt. 4, Box 316
Advance, NC 27006
Re: Site Evaluation
Gordon Drive
Dear Mr. Hamilton:
On May 11, 1989, 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