P5202 Peoples Creek Rd DAVIE COUNTY HEALTH DEPARTMENT
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' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*410TE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Trgment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name s% �' �(i 7rf� �fry'�� . .-.cg�J-r' Date ���/, � F:YLt :► 0
Location %S .5 ,f—174L 7
} /��- c /: •liF �,rJ ,�1. I �''
1
Subdivision Name Lot No. Sec. or Block No.
Lot Size11 House Mobile Home _ Business Speculation
No. Bedrooms �// No. Baths No. in Family
Garbage Disposal YES NO Q Specifications for System:
Auto Dish Washer YES NO .Q
Auto Wash Machine YES NO Q .f
Type Water Supplyrs.
*This permit Void if sewage system described below is not installed within 36 mont ro d to of issue.
U-�
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i
Improvements permit by
*Contact a representative of the Davie County Heal h epartment for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completio el M
one Number: 704-634-5985.
Final Installation Diagram: System Installed by
i
Certificate of Completion Date 60
"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 Q�
Davie County Health Department V�d St?
Environmental Health Section
R O. Box 665 GG /
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 4LIs `l,8i9 Atli)
1. Permit Requested By ��`��- Ro1��t�e�*J Business Phone 111-MOS i4
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional �O ther Type—
Ground
ype Ground Absorption /
G�-
c) Sub-Division Sec. Lot No.-
5.
o.5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people 4"
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 4" 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 4 urinals O garbage disposal �
lavatory + showers 4- washing machine
dishwasher 1 sinks S
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions (o `/z Aexs
b) Land area designated to building site 5�� �� vn*
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Wo
What type?
This is to certify that the information is correct the b st of my k o ge.
Date V Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
0
HD(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)
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 , 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.
g13,A-7
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
—eOnly those listed below
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
`Q SOIL/SITE EVALUATION
Name �� `2 \ �^ Date
Address S2 A �s Lot Size
FACTORS AR 1 ARE AREA 3 AREA 4
1) Topography/Landscape Position S S
bs PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, . S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S
PS PS PS
U U U
5) Soil Drainage: Internal `� , S S
6J Vr� PS PS
U U U U
External S S
pS PS PS PS
U U U
6) Restrictive Horizons 3 T�
7) Available Space S6Ej S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS P PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUI PS— Wally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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I/UCHD(6 82) '1
tti�ie (9vuntg Pealth Pepurtment
anb Pante Rculth �S nrg
P. O. BOX 665
Anrksl1ille, Nortil Carolina 27028
CONNIE L.STAFFORD.BA.MPH TELEPHONE
Health Director (704)634.5985
September 8, 1987 (704)634.5881
Mr. Steve Robertson
464 Heritage Dr.
Lewisville, NC 27023
Re: Site Evaluation
Peoples Creek Rd.
Dear Mr. Robertson:
On September 4, 1987, as you requested a representative from
this office visited your site and found the soil provisionally
suitable for the installation of a ground absorption sewage system.
If you have any questions, please feel free to contact this
office.
Sincerely,
Charles Little, R.S.
Environmental Health
Enclosure
CL/wd