166 Haywood Dr Lot 6 P►v j Davie County Health DepartntntS��,
1836 onmental Health Section
P.O. Box 848 _ •
2 ti0 210 Hospital Street ,t•S)-�-:
O S�Q Courier# : 09-40-0l
Mocksville;NC 270 • 1911
Phone:(336)-753-61 0'' *T C iTTi �x7TERlv O Fax:(336)-753-1680
(Check One) Replacement Remodeling Reconnection
Name: DICK A- 12 r 9,<,,21-1 t4o ly 7— Phone Number 334� 19� - 72�f' (Home)
Mailing Address: s' W,1/VG 6(A-(2C. OV GN 43 L/,92_- �1'T.S (Work)
Email Address:
Detailed Directions To Site:_ - !V6 Fu - Z,i�'1`T /P- b Oe�/Gl P
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_jZIZ ARDoy sir' Q ry !art- P/o 1-0-� (n
Property Address: l -{�f.rW 6-0 n 12 ZfVA&yc 4e, L
Please Fill In The Following Information About The EXISTING Facility: PAral �" 61 000DI) I (q(`]
Name System Installed Under: Type Of Facility: ;�.Q SI&,,r,-U_
Date System Installed(Month/Date/Year): Number Of Bedrooms:
Of People:
Is The Facility Currently Vacant? Yes No If Yes,For How Long?
Any Known Problems? Yes No Yes,Explain:
Please Fill In The Following Information About The NEW Facility:
Type Of Facility: 9AP-fl 6 4,w Number Of Bedrooms4l__Number of People_y
Pool Size: Garage Size: 6Y 249 Other:
Requested By: Xa 16—PDate Requested: —.2 -- &
(Signature)
For Environmental Health Office Use Only
Ap roe Disapproved
Comments:
Environmental Health Specialist Date: l 3
*The signing of this form by the Environmental Health Staff is in no way intended,nor should be taken as a guarantee
(extended or limited)that the on-site wastewater system will function properly for any given period of time.
Payment: Cas Check Money Order # Amount:$ S0O9 I er(A Date: MI
Paid By: Received By: to-.,
G]�{ ��OZS
Account#: -' Invoice#: 7$5s
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• APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Pc�p
Davie County Health Department
Environmental Health Section
P. O. Box 665 GO
Mocksville, N.C. 27028 CG.0-
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMITSHAS BEEN ISSUED.
THo�rs�s J y x' Home Phone
1. Permit Requested B / Business Phone
2. Address E
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 ey Sec. Z Lot No.
5. System used to serve what type f cility: House_IMobile Home Business
IndustryOther
b) Number of people
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms—Bath Roomso-2_—L_1__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 w9r-using fixtures: r>
commodes ..5 urinals garbage disposal [6
lavatory -3 showers 3 washing machine
dishwasher t/ sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes o
9. a) Property Dimensions .9 6W-F.e—S
b) Land area designated to building site �Gt CP_e S
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? ,L(/
What type?
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:
010
DCHD(6.82)
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' a5 W![U11 YW THE PROPERTY/NOWN ON .f��,�-f (,LCAT• Cb �t 1+'+ •+ yZ�,
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i_tC THIS PLATT y SURv O ! ALLIED LAND 18 Wl INO CO. SOS NO.,
LARRY L.CALLAHAN SURVEYING-to INQ• '
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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. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
Haywood Dr. ,Valley View Farms (office use only)
Sec.2 Lot 6
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the aboQve described property, however, I certify that I
have consent from --er , 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 s tem.
IrL Ay
DATE
4. 1 hereby authorize the Davie County Heal h Department to releas site
evaluation results from the above described property to the following:
— Owner only
x Owners designated representative
Anyone requesting results
Only those listed below
f
DATE SIGNATU
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL//SITE EVALUATION
Name ��� �" \ `�` A5 Date `
Address S ��� Lot Size
FACTORS ARE D1 ARE 2 AREA 3 AREA 4
1) Topography/Landscape Position 0 S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) C P PS PS
U U U U
3) Soil Structure (12-36 in.) � S S
Clayey Soils P <_P5 ) PS PS
U U
4) Soil Depth (inches) S S
p A PS PS
U U U
5) Soil Drainage: Internal S S
CID PS PS PS
U U U
External S S
(J�) PS PS
U U U U
6) Restrictive Horizons
7) Available SpaceS ( S S S
PS PS
U U U U
8) Other (Specify) S S S S
PS S PS PS
U U
9) Site Classification 7S
U—UNSUITABLE S— PS�V�v nally Suitable
Recommendations/Comments:
\
Described by - Title ✓�c� w "� Date -1 `6�
SITE DIAGRAM
UCHD(6-82)
Dade, County .Zfealtlf De artment
e Aealtk
and �{om 9 cy
21 O HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE:(704)634-5985
July 13, 1988
Ferrell Realty Co.
Attn: Larry Williams
2727 Reynolda Rd.
Winston-Salem, NC 27104
Re: Site Evaluation
Thomas & Gay King
Valley View Farms/Sec. 2-Lot 6
Dear Mr. Williams:
On July 13, 1988, 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 E. Little, R.S.
Environmental Health
CL/wd
Enclosure
r+a•a < '' —n'Vti..s 'r l-♦. .i'vY wro :h...y... .. i, ; .. -._� 3n - f ....... ..-- .. .. _
DAVIE COUNTY HEALTH DEPARTMENT 6
. 0
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION bp;v
•;"NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c ( 1�/W
r
-' i� Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) -I Pe mit Number
re
me c o t Date �'� - ,� Nps .
Location
Subdivision Name Lot'No. r Sec. or Block No.
Lot Size H ��� , House_ V"_ Mobile Home_ Business, Speculation
No. Bedrooms r
No. BathsNo. in Family •
Garbage Disposal cYES.[T,, NO .❑ Specifications for System: -
Auto Dish Washer YES p� NO'❑
Auto Wash Machine �VESI EE(l. NOS{]
Type Water Supply
*This permit.,Void if sewage system desctibed below.is not installed within 36 months from date of issue.
iv(,f
IN
a
Improvements permit bye..
*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
!C
/,�
. Certificate of Completio = - Date
"The signing of this certificate shall indicate that the system descri a above has been, installed in compliance with
the standards set forth in the above regulation, but shall in NO wa_y be taken as a guarantee that the system will function
satisfactorily for any given period.of time.
i f ? APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department 21 "//?
Environmental Health Section
P. O. Box 665
t Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEI�•I LIED.
/521
Home Phone
1. Permit Reques d By o Business Phone
2. Address a ��
3. Property Owner if Different than Above
Address /
4. Permit To: a) InstallI Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile ome Business
IndustryOther
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms---,f —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 Community
b) Has the water supply system been approved? Yes_bZNo
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
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.
c
Date Owner Signaf
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
1 L 3
w �
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
f
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS ARE 1 ARE AREJG AREA
1) Topography/Landscape Position S SSS
<fN) I cm 6
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) -P PP rp,31-1 (t
U U U
3) Soil Structure (12-36 in.) S
Clayey Soils pp j �PS� n5:4, 4
U
4) Soil Depth (inches)
P `ems ck
U U
5) Soil Drainage: Internal
b P 4PS
U U U
External j S�
C
6) Restrictive Horizons
7) Available Space PSS S` S
S
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification S S V S S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: ° A-L"=� QA �
G - achy
Described by ��-���\ Title Date J
SITE DIAGRAM
DCHD(6.82)
t