231 Burton Rd �.e- it _ • - t.. . . •. ', - •- _ -
�," DAVIE COUNTY HEALTH DEPARTMENT-
- IMPROVEMENTS. PERMIT AND CERTIFICATE OF COMPLETION:'
*W'! TE: Issued in Compliance with G.S. of North Carolina Chapter,130 Article. 13c i
Sewage Treatment and Disposal Rules (10 NCAC"10A .1934-.1968) ' . .Permit Number
Name ' R <l 1 S r Date, '50-52
Location
'\lvo fSr.
Subdivision Name Lot No, Sec. or.Block No.
LotlSize .16 -Wx I �3 House r Mobile Home.—I_A�3 Business Speculation
No.�113edrooms No. 'Baths No. in Family
Garibage.Disposal YES ❑ NO Q `.
Specifications for System:
Auto Dish Washer. YES ❑. NO-.0
Auto W11 ,ash Machine_ YES ❑ NO ' p U ti )( 1
-Type Water Supply X
-'C., -
"This permit Void if sewage system descr'ibed below is not installed within 36 months from date of issue.
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- dray of j99mpletion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
fl b6�
j - :-Certificate of Completion Date 1
'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 regulatidm, but shall in NO way be taken.as a,guarantee.that•the system will function-
' satisfactorily for any given.period of time.
46^*
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section R�(j
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 49a, -7 ID 7 3
1. Permit Requested ByC C�-111 Business Phone
2. Address ' 0
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
Industry Other
b) Number of people-3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensionsq$
Bed Rooms—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 a' urinals garbage disposal
lavatory showers washing machine
dishwasher ( sinks
8. a) Type water supply: Public Private CommunityJ�
b) Has the water supply system been approved? Yes v1 No
9. a) Property Dimensions X64 � 3 53
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 ate Owne Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLI CE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: $0 S I_ ?(2C)p'C_S CLQ RC) . meQ. '19fAl't
-to #1 �lo �5 rn L� o-►` -�- .
a
4 C4 r
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
-qj , Rd 164 6 (office use only)
4o.k. Sol -6 St-W. 1bso +„i 1,ya
Des 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 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 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.
,1.,l r.11 �,, �-, 4- /��I,
bAtE SIGNATURE
4. 1 hereby authorize the Davie Coun 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
D TE S GNATU E
DCHD(11/84)
HOWELL W. WOLTZ
DB. 133 PG. 808
131 568 existing iron pin
Ll yjC90
/ POTTS REALTY INC.
t o
�t S� DB.138 PG. 747
30 j
l ral
nail co new iron pin N 870 59'34
center od new iron pin
33.50
320.13
2 � C � H
N O
0 AAREA = 0.712 ACRES
o o DALE R. DAVIS
w p ( INCLUDES SR. 1646 R/W) 0 DB. 140 PG.824
cps m
e �
33.50 274.04
note Cap *fisting iron pin +—S 880 10'41 W 307.54 TOTAL existing Iron pin
1.6west nter road
per
013
0. N
Ma DALE R. DAVIS
DB. 140 PG. 824
�o
9Q
' TOLERANCES REVISIONS SURVEY FOR
.0. DATE .. POTTS REALTY INC.
-T oeurwL 1 BEING 0.712 ACRE TAKEN FROM THE POTTS REALTY INC.
°-' -- -. -- •��. •. PROPERTY(DB.138 PG.747) LYING IN SHADY GROVE
'•' `L^''�'`�= ^',:'fit'-. ^ •wwrnoMwL TOWNSHIP,DAVIE CO.,N•C.
DR^""I SCALE I"- 40' MATERIAL
CMK'D B.F.D
_____-___.__..__ «.-•r• -. .. i"ti £ weau Lww D G.L.T AT, 1.,5_138 IS_BB KAw,�D No
D
A- 688-2
1
r .
� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date ra $9
Address 'S� ci Lot Size
FACTORS AR 1 A A 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
Qb S PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) P PS PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils S PS PS
U U U
4) Soil Depth (inches) S S
PSPS PS PS
U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S
pS PS PS PS
U U
6) Restrictive Horizons
7) Available Space S S
pg PS PS PS
U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by C-- Title � Date
SITE DIAGRAM
' 0
1-4 (
DCHD(6.82)