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305 Clayton Dr CP 0 DAVIE COUNTY HEALTH DEPARTMENT %'• IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II f G.S.Chapte .130a ��, a I U �J ct " Sanitary Sewage Systems C/o �ah b�`nw el Permit Number Date / -_� 1630NO Name _�' .z--�_'�-9,� 6 813 Lo-c-ac�tion .—,T :�� •.� ,r - :r'rte -2""/ � ri ,�, _ v Subdivision Name Lot No. Sec. or Block No. Lot Size ,429-l' House,,/ Mobile Home _T Business _— Speculation No. Bedrooms No. Baths' No. in Family __ Garbage Disposal YES ❑ No Specifications for System: Auto Dish Washer YES NO ❑ , r Auto Wash Ma shine YES NO ❑ �C.�©G%/��r e_ Type Water Supply *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. t 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 r � ✓Certificate/ of Completion Ila�'C 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. SID APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �l0�3 � / vie County Health Department FAR IC flEnvironmental Health Section 1pC I n P. 0. Sox 665 Mocksville, NC 27028 O 1 . Application/Permit Requested By CA Lnmo-4F-cEI Mailing Address Home Phone 1 - 7�0 U� 3 Business Phone 2. Name on Permit if Different than Above 3. Property Owner if Different than Above 4. Application/Permit For: General Evaluation 0 S/Tank Installation S. System to Serve: .8-iTouse u Mobile Home 0 Business L Industry u Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Lot* No. of People Dwelling Dimensions -01A No. of Bedrooms Basement/Plumbing No. of Bathrooms 2 Basement/No Plumbing ;.8-Washing Machine .a-Dishwasher „g-Garbage Dispusai 7. If business, industry, other: Specify type �— No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories No. of Water Coolers No. of Showers 8. Type of water supply: C Public 9--irrivate D Community 9. Property Dimensions 10. Sewage Disposal Contractor 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? - Yes 2--No AML- If yes, what type? *NOTE: Improvements Permits , shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. -IU-90 Lam Date ignature Directions to Property : JD DCHD (10-89) �i DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name C� Date Address s AQ Lot Size 7 �� FACTORS A EA 1 A EA 2 AREA 3 AREA 4 1) Topography/Landscape Position pS PS U U U U 2) Soil Texture (12-36 in.) Sandy, --- S S Loamy, Clayey, (note 2:1 Clay) PS PS PS U U U U 3) Soil Structure (12-36 in.) S S Clayey Soils PS PS U U U U 4) Soil Depth (inches) S S • PS PS PS U U U 5) Soil Drainage: Internal S S S �' PS PS PS U U U ExternalS S P-� PS PS PS U U U 6) Restrictive Horizons 7) Available Space S S PS PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U 9) Site Classification U—UNSUITABLE �rS—\ ITAB t l SPS— isionally Suitable 1 'C-6 1 Recommendations/Comments: Described by Title • S Date C)D SITE DIAGRAM DCHD(6-82) � 19G 4 k l{00 »> i ooatc it ory IVP' U '{ bo co 40 1p3L , 1A w 1 13 i C . 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 /D (office use only) Cyes 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. 1 � i 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 16p h)n DATE SIGNATUR DCHD(11/84) Davie County NealtI.,7�oDe artment NaltFi yn and me e e cy 210 HOSPITAL STREET I P.O. Box 885 MOCKSVILLE.N.C. 27028 PHONE:(704)834.5985 February 26, 1990 Ms. Meg Lomax 1400-1 Birkner Ave. Winston-Salem, NC 27103 Re: 4 Site Evaluations & Permit 5856 Pudding Ridge Road Dear Ms. Lomax: On February 23, 1990, as you requested a representative from this office visited the above mentioned location. The soil was found provisionally suitable for the installation of a ground absorption sewage system on each of the four sites. Permit 5856 was issued for a barn- apartment to be located on the first site. If you have any questions, please feel free to contact this office. Sincerely, Q5� �. �.s. Charles E. Little, R.S. Environmental Health Section CL/wd Enclosures . --� •,:. DAVIE COUNTY EALTH DEPARTMENT $ o IMPROVEMENTS\OERWIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article II of GS,Chapter.�30a: Sanitary Sewage Systems 'J ` c.,h ` 'Permit Number +' C' NameDatL--- f N2 5856 Location t y �`-� , � . '� 1\=_`-' \)J .� o-�'-- - +I�h �L. ,�I0. V\A QI __. VA ' Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home'`` Business Speculation No. Bedrooms No.'Baths k No. in Family Garbage Disposal YES ❑ NO p' Specifications for System: Auto Dish Washer YES ❑ NO Q Auto Wash Machine YES NO ❑ Type Water Supply *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. P)J .ate 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. 1='nal-Tstallatio�(D am: _ f�:;�- System Inst�1lgi by Certificate of Completion Date Z1.2_ZZk)_ "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. ' ~' n•a� S PERMIT APPLICATION FOR SITE EVALUATION/IMPROVEMENT Davie County Health Department - V1% A_e`p� �� Environmental Health Section P. 0. Box 665 �_ I Mocksville, NC 27028 �m2� FEB 6 1994 REC 1 . Application/Permit Requested By zp � �YY1 Mailing Address 1400 -1 6k r'�-ne-y- Wye . Wins(��',�Lem Y lP x� 10-5 Home Phone (� �f�?-hoyT7 3 Business Phone (0 2. Name on Permit if Different than Above _ 3. Property Owner if Different than Above 4. Application/Permit For : 0 General Evaluation /Tank Installation S. System to Serve: 0 House [] Mobile Home 0 Business 0 Industry Czr-8•ther 0 Unknown 6. If house, mobile home: Subdivision Sec. Lot# No. of People Dwelling Dimensions AtAW todOG 2� 2 No. of Bedrooms Basement/Plumbing No. of Bathrooms Basement/No Plumbing L' -�� L \R-Washing Machine (J' Dishwasher I 0 Garbage D:ispusai 7. If business, industry, other: Specify type '6ARIJ W ism . �QT No. of People Served No. of Sinks No. of Commodes No. of Urinals No. of Lavatories �;�� � No. of Water Coolers — No. of Showers 1 �`►��� 10 7 , 8. Type of water supply: C Public B-Private Q Community 9. Property Dimensions 1 r] 4CPt . 10. Sewage Disposal Contractor ? Dos ? 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? 0 Yes 2-v'o If yes, what type? *NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges incurred from this application. a-io- 9a Date Siq ature Directions to Property : �e T\L/, LD 4°D «< '� ucoi ooa S-afi� HHH NFF ' a t c tf1 rS c.F Poe i ( 3) (p ,� DAVIE COUNTY HEALTH DEPARTMENT _ Environmental Health Section. � r P. O. Box 665 — Mocksville, N.C. 27028 SOIL/SITE EVALUATION n Name \ �, 2 a C '� - Date d ^ 3 u Address 5 A'me Lot Size I � FACTORS A EA- 1 ARCA 2 ARI AR 1) Topography/Landscape Position S SSPS S--� U LF 2) Soil Texture (12-36 in.) Sandy, S S Loamy, Clayey, (note 2:1 Clay) �P5PS U U 3) Soil Structure (12-36 in.) S � ��� Clayey Soils U U U 4) Soil Depth (inches) Gi; �S S PS PS U U U U 5) Soil Drainage: Internal S PS P 'AP7 L.�U / Tp t� U U External IS PS PS PS 6) Restrictive Horizons ---- _ 7) Available Space S S pg cps � PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U 9) Site Classification - U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recomjnendations/Comments: -`� VIA 3 pD� Described by ��`� Title ` \A 5 Date SITE DIAGRAM R (� t 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, R O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED f'Y�/N�10/�� (office use only) 2 yes no 1. I 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. ryes 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. �� ;-- [L 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 l5!t----Anyone requesting results — Only those listed below DATE SIGNATUR DCHD(11/84) Davie County NealtI De artment and ,7�ome Naltl Aen e y cy 210 HOSPITAL STREET I P.O. BOX 665 MOCKSVILLE,N.C. 27028 PHONE:(704)634.5985 February 26, 1990 Ms. Meg Lomax 1400-1 Birkner Ave. Winston-Salem, NC 27103 Re: 4 Site Evaluations & Permit 5856 Pudding Ridge Road Dear Ms. Lomax: On February 23, 1990, as you requested a representative from this office visited the above mentioned location. The soil was found provisionally suitable for the installation of a ground absorption sewage system on each of the four sites. Permit 5656 was issued for a barn- apartment to be located on the first site. If you have any questions, please feel free to contact this office. Sincerely, Q5� Charles E. Little, R.S. Environmental Health Section CL/wd Enclosures