2246 Hwy 801N DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION,
*NOTE: 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—__ �� .ry->��`'•. . Date /° ` �r . � 3779
Location %,
Subdivision Name Lot No. Sec. or Block No.
Lot Size House
/�f _ r_.
. Mobile Home _ Business•-- Speculation '
No. Bedrooms — No. Baths _ % No. in .Family
Garbage Disposal YES '� NO D,- Specifications for System:
Auto Dish Washer YES NOEl
Auto Wash Machine YES C7 NO
Type Water Supply „/ t -- f X.a11 .rx �V �
`This permit Void if sewage system des rib 'd below isnot installed within 36 months from date of issue.
J
Improvements permit by r
.,/. .
*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.
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Final Installation Diagram: System Installed by
v % .
Certificate of Completion _- 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,take.n:as a guarantee that the system will,function
satisfactorily for any given period of time.
. t
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— � Date
f
Address a.�'./lLot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS . ,
cU U
2) Soil Texture (12-36 in.) Sandy, - S S SS
Loamy, Clayey, (note 2:1 Clay) p�, PS
3) Soil Structure (12-36 in.) S S S S
Clayey Soils - PS
4) Soil Depth (inches) S S S
PS PS PS
5) Soil Drainage: Internal S S S S
PSU
External S SS
PS PS P
U U U
6) Restrictive Horizons /� f .�,J � j �J`ti•:
7) Available Space S S. S S
PS' PS
U U U
8) Other (Specify) S S S S .,
PS PS PS PS
9) Site Classification v.- S7 R , . v • S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(6-82)
DAVIE COUNTY HEALTH DEPART-HENT
SITE EVALUATION CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2. Along with the form, remit the amount due as shown on •enclosed statement.
3. Carefully follow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARTAIENT,P.O. BOX 57)
(MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FOP11
LOCATION OF PROPERTY: DATE RECEIVED
13.4 ,4c-9,E5 ON 14wy 80 �� NZlP, Z�rr R sCCTi'a/( (office use only)
OF FARn4;NGroa R014d. Sze MAP
yes' no (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described property, however, I
! certify that I have consent from R;e11,44 I LEE'S _,owner to
owner's name
obtain a site evaluation by the Health Department for the purpose
of determining the suitability for a ground absorption sewage
disposal system.
yes no (3.) I 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 necessary to
determine its suitability for a ground absorption sewage
disposal system.
DATE USIGNATURE
(4.) 1 hereby authorize the' Davie County Health Department to release
site evaluation results from the above described property to the
following:
0. Owner Only
tj Owner's designated representative
-/�-F3 0 Anyone requesting results
DATE Only those listed below
5V. Alo-ayL.4- Q'� 4
SIGNATURE
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 999-5'110
1. Permit Requested By Business Phone 17A;1 -330,2
2. Address �o
3. Property Owner if Different than� Above `
Address 3`I a.0 �f j ec s- Pit',��// q _j
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: Housed Mobile Home Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �/0 x lea 0
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) *A
7. Number and type of water-using fixtures:
commodes z urinals garbage disposal
lavatory showers washing machine /
dishwasher sinks
8. a) Type water supply: Public Private—X_Community
b) Has the water supply system been approved? Yes No-)L
9. a) Property Dimensions 5 erZ B
b) Land area designated to building site /3, 4 A 0IRJES
c) Sewage Disposal Contractor NOT S g*&Ted v E7
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.
7-//-
R3
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
NoTF; old RoAd zs.
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DCHD(6-82)
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P. O. BOX 665
c4laclssilille, Yorth Carolina 27628
OFFICE OF THE DIRECTOR TELEPHONE
17041 834-5985
July 28, 1983
John H. Davis
Route #4, Box 155
Advance, North Carolina 27006
Mr. Davis:
This letter is to confirm our conversation on July 22,
1983 regarding a tract of land evaluated by this office in the
Farmington Township of Davie County. As discussed on said
date, this office feels a shallow septic tank system can be
installed and should function properly if properly maintained.
The area where the septic system must go is along the upper
ridge that is on the north side of the property. To reach
this area the house must be set back along the wood line or
a pump must be installed so the sewage effluent can be pumped
to the provisionally suitable area.
If you have any questions, feel free to call.
Sincerely,
Robert B. Hall, Jr. R.S.
jh Sanitarian