620 County Line Rd •Y .i a /60, r-� /•�
V j'� DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION l y -0
*NOTE:_ Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
,
Name \ ��, V�� c.\7.1 Date - 1 - l Np 5
r
814
Location
1, ✓
VA
Subdivision Name` Lot No. Sec. or Block No.
Lot Size f_ 1 '� `+' ,House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES p' NO ❑ Specifications for System: �.
Auto Dish Washer: YES F1 NO d
Auto Wash Machine YES p' NO ❑
Type Water Supply `.
*This permit Void if sewage system described below isnot installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
XZ
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
1'a S
u �
r %\
Certificate of Completion �cx 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.
V
eD APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
r� Davie County Health Department 13
1 p/' Environmental Health Section E
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 492-5790
1. Permit Requested By RONALD LEE WICKER Business Phone 634-2371
2. Address ROUTE 6 'BOX 123-4 M0Q(gVILLF NC 27ngg
3. Property Owner if Different than Above MRS. AGNES WOOTEN
Address ROUTE 1 BOX 351 HARMONY NC 28634
4. Permit To: a) Install--L Alter Repair
b) Privy Conventional_Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House X Mobile Home Business
IndustryOther
b) Number of people 244
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions 2000 SQ. FT.
Bed Rooms?-3 Bath Rooms 2 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 2 urinals garbage disposal 1
lavatory 2 showers 2 washing machine 1
dishwasher sinks 2
8. a) Type water supply: Public X Private Community
b) Has the water supply system been approved? Yes Nom
9. a) Property Dimensions 18 — 20 AC
b) Land area designated to building site 1 AC
c) Sewage Disposal Contractor NOT YET SELECTED
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? NO
What type?
R
This is to certify that the information is co to the best-of my knowle
Date ner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
TAKE 64 WEST FROM MOCKSVILLE TURN RIGHT ONTO 901,TOWARDS HARMONY. TURN
RIGHT ONTO FIRST PAVED ROADqQNTY LINE ROAD — STATE ROAD #1338). GO
APPROXIMATELY 1.10 MILES TO BOTTOM OF HILL AT JAMES LEWIS PROPERTY.TURN
RIGHT OFF OF ROAD INTO PASTURE AT ORANGE FLAG. FOLLOW WOODLINE ON RIGHT.
. GO APPROXIMATELY 750 FEET TO ROW OF PINES AND CEDARS. WALK THROUGH OPENING
STRAIGHT TO RED BANDANA ON STAKE (APPROXIMATELY 300 FEET). THIS IS THE
PROPOSED AREA FOR SEPTIC TANK AND LEACH FIELD.
PROPERTY FOUND ON COUNTY TAX MAP H-1 PLOT 10.
i` *NOTE: Improvements Permits shall be valid for a period of 5
it years from date issued. Improvements Permits are subject
j' to revocation, if site plans or the intended use change.
Effective October 1, 1989.
DCHD(6-62)
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
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
COUNTY LINE ROAD - STATE ROAD #1338
yes no 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 MRS. AGNES WOOTEN° 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.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described propertyand 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
— Owners designated representative
—Anyone requesting results
X Only those listed below
RONALD LEE WICKER
OLENE TAYLOR WICKER
DATE NATURE
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 Mp Lot Size
FACTORS AR 67> A F I A 2 AR 3 AREA
1) Topography/Landscape Position <Z:::h S
P
U U U
2) Soil Texture (12-36 in.) Sandy, S _
Loamy, Clayey, (note 2:1 Clay) 6 <f PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils d>U U "
4) Soil Depth (inches) P S � S .,
U' U
5) Soil Drainage: Internal S S
...: U
External -!�A
PS
U U
6) Restrictive Horizons
7) Available Space S S
S PS PS
U U U U
8) Other(Specify) S S S S
PS PS PS PS
U
9) Site Classification S Kt'3� S
U—UNSUITABLE S—SUITABLE PS— r visionally Suitable
Recommendations/Comments: �` _ 1
Described by Title Date -l o —
SITE DIAGRAM
s-
g
J
!l
V
DCHD(6-82)