134 Crosswind Dr Lot 5 ;. ._ DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETI N
*NO`T'E:Issued in Compliance With Article II of G.S.Chapter 130a 3�f &/-Osu'a1rn���i
Sanitary Sewage Systems Permit Number
Name M� 5���>toZJ �J Date t i ..) NO 632
Location �t1 , Q:_ N.N6 C=, �, }� ��;•- C\ `1��' t�
1 � d��.r �� �`n [,: �� ..� �1 � \! n.�`-f�'`l. L.T�• 1�4 �� ���t \��4_j\T.•iT -aca":'l\�
Subdivision Name Lot No. �� Sec. or Block No.
Lot Size House 1t1 Mobile Home —� Business -- Speculation
No. Bedrooms .No. Baths 1 No. in Family _
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES [�' NO ❑ f b � 1
Auto Wash Machine YES p- NO O
Type Water Supply
v
'This permit 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.
1.7
Improvements permit by``'~
"Contact a representative of t -e'6a ie-6otirt ealth-Depadment..fox-.f I inspection of thisystem b tween 8:30 7�
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: -634-598 .
Final Installation Diagram:: System Installed y �� 1
c
_ Ol -
1
r'o O
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 regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
cgl-L BACK-
APPLICATION
HcKAPPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT-ffl#
S ` Davie County Health Department �0
Environmental Health Section OC
J P. O. Box 665 [BGG
( Mocksville, N.C. 27028 /
l
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
I,, � Home Phone—
ted
hone
1. Permit Requested By _ Cil1Y11 �► o_ngzx) l J�E�S Business Phone
2. Address Co>7Ylde el
3. Property Owner if Different than Above - - �-'• Jd� �) Y�olc a 77/�
Address , • �
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division ��rn�n+�un ��5ec. Lot No. 5
5. System used to serve what type facility: House—Ne!fMobile Home Business
''II // IndustryOther
b) Number of people l�D�.'f OreserlHu op
6. a�If house or mobile home, state size of home and numbet of rooms. b eYRclle,&
House Dimensions 4&�X� -6-.q-X`fir 1
Bed Rooms Bath Rooms_Den Lkp > orae )
b) If Business, Industry or Other, State: Number of persons served NA
What type business, etc. NA
Estimate amount of waste daily (24 hours)_t�a
7. Number and type of water-using fixtures:
commodes urinals n garbage disposal I
lavatory showers 3 washing machine
dishwasher sinks 0. ailcitn , ,hasen 4
8. a) Type water supply: Public V/ Private Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions ,51 ACrroS - AWalu Ap bo Arau w In M4 82 We&s
b) Land area designated to building site _O:�
c) Sewage Disposal Contractor rlo f)A have 0012 Leel
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? N6
What type? N A
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: ��� • L -�G ,,7 I C
h yo -
ojc"U ay_' ate(, a J,_O�
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:: 11� I1DATE RECEIVED
.,6+45 M�,monf le4a4ibn Aavo-nx,JAL' (office use only)
yes ® 1. I am the owner of the above described property.
Ono 2. 1 am not the owner of the above described property, however, I certify that I
have consent fromma&a.0 �eU owner to obtain a
owner' ame
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 conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
0� v
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
V Anyone requesting results
Only those listed below
I 5-89 at�2
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
" Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name / Date
Address Lot Size��L`'
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS (�'S) PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) &P PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils DAM
PS PS
U U
4) Soil Depth (inches) S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS
U U
External SS S
((ASS) PS PS
l U U
6) Restrictive Horizons A/o C../
7) Available Space (3> 0 S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by / Title Date
SITE DIAGRAM
� 8
p
DCHD(6-82)
Davie County Aealf!i De artm,
and dome Xealb ency
210 HOSPITAL STREET/P.O.BOX 665
MOCKSVILLE.N.C. 27028
PHONE:(704)634-5983
December 19, 1988
Jami Shannon Oates
1562 Twin Oaks Dr.
King, NC 27021
Re: Site Evaluation
Marchmont Plantation
Section 1/Lot 5
Dear Ms. Oates:
On December 13, 1988, 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; however,
the house must be staked off before a permit can be issued.
If you have any questions, please feel free to contact this office.
Sincerely,
Robert B. Hall, Jr. , R.S.
Environmental Health Section
RH/wd
Enclosure