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1160 County Home Rd f.,.,s-�.<...t..:«>t+',:9'.-.,.a-a.rAf ;:.d:.o .,:s.r-r.�, ',',i:y'D .1; .•";1' .. , -.:r-,f. -t. ..'� x „... i1` . , -b:- ... ,., .. . .... DAVIE COUNTY HEALTH DEPARTMENT 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 N2 5255 Loc4 —Ja). //loD doglnlil ZC1' Subdivision Name Lot No. - Sec. or Block No. Lot Size %%' House Mobile Home _ Business Speculation No. Bedrooms 04 No. Baths c�2 No. in Family_ �— Garbage Disposal YES .Q NO Q'' Specifications for System: Auto Dish Washer YES Q NO Auto Wash Machine YES p NO C) r! Type Water Supply "This permit Void if sewage system described below is not installed within 36 months from date of issue. pus b" Improvements permit by 'Ili I '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 DateJ 'f-- '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. > ` APP©DATION FOR SITE EVALUATION/IMPROVEMENTS. PERMIT. If�P q� Davie County Health Department �I Environmental Health Section P. O. Box 665 , ok �� Mocksville, N.C. 27028 RECEryED JUN i 5 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested By &OK u,L_L(s• da, Business Phone 2. Address 3128 C V W d "CE, ®62.01"SC. a If-0g.- 3. S-ag.-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—Business IndustryOther b) Number of people 6. a}If house or mobile home, state size of home and number of rooms. House Dimensions I6.2S - 5 - E'. ' Bed Rooms_—Bath Rooms 'I 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 �3 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 ''f�No 9. a) Property Dimensions /2G 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 corr t to the best of my knowledge. �-118 Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: 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. O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED ,►3Fo2D nUeQC E (office use only) t e I -6a i!4 37 MOO-KS(/ttze, es no 1. I am the owner of the above described property. yes no 2. 1 a owner of the above descr' ertify that have m owner to obtain a owner's nam site evaluation by the County Health Department-for the purpose of determining the suitabili for round absorption sewage treatment and disposal system. yes 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. 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 —Qwners designated representative ✓Anyone requesting results —Only those listed below DATE SIGNATURE DCHD(11/84) ff I I ! I I - i I ' I t DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION p� Name v/� s ' Date Address Lot Size 1 � FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S (PS") PS PS PS U U U 2) Soil Texture (12-36 in.) Sandy, ��,,.. S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils (PS) PS PS PS U U U 4) Soil Depth (inches) S S S PS PS PS U U U 5) Soil Drainage: Internal S S S PS PS PS PS U U U External S S S PS PS PS U U U 6) Restrictive Horizons �- 7) Available Space S S S S PS PS PS PS U U U - 8) Other (Specify) S S S S PS PS PS PS U U UU 9) Site Classification f1 r U-J•r te-0. L� U—UNSUITABLE S—SUITABLE y� PS—Provisionally Suitable Recommendations/Comments: '7�eflr/wtr 'C Described by Title �, �>'►� - ---- - Date SITE DIAGRAM y DCHD(6-82) r Davie Cazgl Aeab 7,e arlmenf and ala e Nl alt n . m e cy 210 HOSPITAL STREET/P.O. BOX 665 MOCKSVILLE, N.C. 27028 PHONE.(704)634-5985 June 24, 1988 Frank Willis, Jr. 3128C Utah Place Greensboro, NC 27405 Re: Site Evaluation Sanford Avenue Dear Mr. Willis: As per your request, a representative from this office visited your site on June 21, 1988, to determine the soil/site suitability for the installation of a ground absorption sewage system. Unfortunately, due to the reasons noted below, we must classify this site unsuitable: 1) 2:1 clay. 2) Unsuitable topography. We sincerely regret this classification and are more than willing to discuss this matter further, upon your request. Sincerely, Awa,4�� .AP Robert B. Hall, Jr., R.S. Environmental Health RH/wd Enclosure