179 Partridge Ln (2) .:..;;-r .':•,.--a ,,+�:.a_-• -i._..,.... ... :':�- .+ y.;:vs 'd. j(i..p:.3, -i. ..-. .e.- S . 4 . . .a. --- 1 •-
*� I\DAVIE ~COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'.NOTE Issued-in-Compliance with G.S. of North Carolina Chapter 130 Article 13c �
Sewaige Treatment and Disposal Rules (10
' NCAC 10A .1934-.1,968) Permit 'Number
Date 3Name JA
Location
�^„�� �✓ y _ l r e'.� - fir', , s :� .� / 1� .
All
Subdivision Name Lot No. Sec. or Block No.
Lot Size rj< House I Mobile Home � Business Speculation
No. Bedrooms No. Baths_ No. in Family _
Garbage Disposal YES Q NO p-" Specifications for System:
Auto Dish Washer YESNO p 1 ///• ' ' 'rC�
Auto Wash Machine
YES NO ❑
ff��ii''
Type Water Supply ZZ
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
14(
F {
F
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
A
i
Certificate of Completion E?� J � 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.
` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department 5
Environmental Health Section cr ��ux 1
P. 0. Box 665
Mocksville, N.C. 27028
r
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone4 03
Permit Reque%e4 By TZ Business Phone
2. Address
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 Se� Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
J
b) Number of people
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 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 Coo unity
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensions 6 CLCJL.Q-,=,
A—
b) Land area designated to building site
c) Sewage Disposal Contractor _ILA-
10. Do you anticipate any additions or expansions of the fac (ty this sewage system is intendeil o serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signatur
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STAT 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
(office use only)
ye 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.
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
— Owners designated representative
Anyone requesting results
— Only those listed below
DATE SIGNATURE
DCHD(11/84)
+' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section..
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name LZ Date
Address Lot Size r
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
? 11 U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) P
a U
3) Soil Structure (12-36 in.) S S p�
Clayey Soils & (�P9
U ''T�j
4) Soil Depth (inches) S S C
PSS PS
U
5) Soil Drainage: Internal S S � S�
S)
U U
External S S
6P PS -PS
U U U U
6) Restrictive Horizons / S J
7) Available Space �S S
S PS P5 PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U{ U U . U
9) Site Classification U� L
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: Z6
Described byTitle �3'1�`� Date to
SITE DIAGRAM
X-2-
k�
DCHD(6-82)
D BY: Daniel L. Timberlake, Attorney.
( ame) (street and Numbe ) (city) (State) (zip)
e tax bills to:
E—(Name) (Street and Number) (city) (State•) (Zip)
OF NORTH CAROLINA , t�Al
Y OF NXWV DAV IE. `J QUITCLAIM..DEED
Men by These presents, That ' DORIS N'. TUCKER and husband. THURMAN TUCKER '
I%County, N.C. in consideration of-
0
f _of RICK STANLEY
ereby released;and forever quitclaimed,unto RICK STANLEY
heirs and assigns forever,all such right,title and interest,as they may - have•in or to all-.that-parcel of land lying
Davie North Carolina-
(Township)
ounty (state) ,described as follows: . .
ATTACHED "EXHIBIT A" INCORPORATED FULLY HEREIN BY REFERENCE.
-(NO .TITLE SEARCH REQUESTED OR•PERFORMED)---
ntor, Doris N. Tucker; has an outstanding• Judr orsyth County, NC.' whicch has...
n'transcribel to- Davie County. Judgment Cred• released and Quitclaims
it interest! in and to' t' he Real Estate by inst• zorded next, releasing•
it lien • to' the Grantee herein.
• � .� rte._ ;''