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175 Haywood Dr Lot 4 ' HEALTH DEPARTMENT RELEASE For office useon►y . *CDP File Number 202182-1 Davie County Health Department f 210 Hospital Street County ID Number. ' P.O. Box 848 HDR/WWC � Evaluated For. Mocksville NC 27028 Phone:336-753-6780 Fax:336-753-1680 PERMIT VALID 0 4 / 1 1 / 2 0 1 6 UNTIL Applicant: G. Jefferson Laws Property Owner: G. Jefferson Laws Address: 175 Hayward Drive Address: 175 Hayward Drive City: Advance City: Advance State/Zip: NC 27006 State0p: NC 27006 Phone#: (336)998-2180 Phone#: (336) 998-2180 Property Location&Site Information Address Hayward Dr. Subdivision: Vally View Farms Phase: Lot: 4 Road# Advance NC 27006 SINGLE FAMILY Township: 'Structure: Directions #of Bedrooms: 3 #of People: _ 1-40 East,exit 180,Hwy 801 go North right on Yadkin Valley Rd.left on Hayward *Water Supply: NIA Type of Business: Basement: R Yes Q No Total sq.Footage: No.Of Employees: *Proposed Improvement: Garage 'Release Conditions This release in no way expresses or implies that the existing subsurface sewage treatment and disposal system serving the site will continue to function for any period of time. Applicant/Legal Reps.Signature Required? Oyes ONo Applicant/Legal Reps.Signature: *Date: *Issued By: 2140-Nations,Robert *Date of Issue: 0 4 / 1 2 / .1 0 1 6 Authorized State A **Site Plan/Drawing attached.** ( Hand Drawing Olmport Drawing HEALTH DEPARTMENT RELEASE e�sTa Davie County Health Department CDP File Number: 202182 1 210 Hospital Street County File Number: P.O.Box 848 Mocksviile NC 27028 Date: ,0 4 / 1 2 / 2 0 1 6 0Inch Scale: , OBiock ft. Drawing Type: Health Department Release ON/A 1� i I � _�___ Page 2 of 2 o s - q0q. w 9� wt Davie County Health Department 4 1836 avironmental Health Section Iv P.O.Box 848 �1 210 Hospital Street .�: ...�. . U;is G Courier# : 09-40-06 Mocksville,NC 27028 Phone:(336)—753-6780 Fax:(336)—751-8786 ON-SITE WASTEWATER CERTIFICATION FOR DWELLING (Check One) Replacement Remodeling Reconnection Name: G. JQf r(-s o n L n W S Phone Number s3 " 99 9 -Z,0 (Home) Mailing Address: 7 Ha\I WDOGI �Y 336,- �3d - Z 18q (Work) 46-a vlc c AL 12-700t, Email u► I la ws @ h1S h ,(-o m Detailed Directions To Site: Property Address: 15 RaNjmod Dv,. AJvaYic/— NC a'] / d, 3bl�g (2- Please Fill In The Following Information About The EXISTING Facility: C'it4. 4- R-&- Name System Installed Under: Type Of Facility: &is4ioi /10 Date System Installed(Month/Date/Year): Number Of Bedrooms:JNumber Of People: Z Is The Facility Currently Vacant? Yes ® If Yes,For How Long? Any Known Problems? Yes No If Yes,Explain: Please Fill In The Following Information About The NEW Facility: Type Of Facility: Af c -to riot v' h oft s/— Number Of Bedrooms: y Number of People -2— Requested Requested By: Date Requested: (Sign e) For Environmental Health Office Use Only Approved Disapproved Comments: Environmental Health Specialist Date: *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 tha on-site wastewater system will function/properlyfor any given period f time. Payment: Cash Check Money der # R Amount:$ / 0 0 Date: b Paid By: /y r n' Received By: Account#: 02 �5 z Invoice#: 175 14A DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number Name = .1' 'r- i:; �r:�'i `- x 7 "a r 9 __r - Date �� _ Location Subdivision Name 15 )Nyl Clutee '� Lot No. '�� Sec. or Block No. �— Lot Size {r% 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 Auto Wash Machine YES p NO p Type Water Supply �_ . f -- ✓rG` 'yS / / '`This permit Void if sewage system described below is not installed within 36 months from date of issue. 1 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. J. Final Installation Diagram: �� ystem nstalled by, ? 2 i 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 taken as a guarantee that the system will function satisfactorily for any given period of time. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S PS PS PS U U U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) l/PS/ PS PS PS �� U U U 3) Soil Structure (12-36 in.) S S S S Clayey SoilsepPS PS PS U U U 4) Soil Depth (inches) S S S PS PS PS PS U U U 5) Soil Drainage: Internal S S S S PS PS PS U U U External S S S PS PS PS U U U 6) Restrictive Horizons 7) Available SpaceS• S S g PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification L7 d- U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: a '5� Described by / Title Date SITE DIAGRAM DCHD(6-82) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 9� Davie County Health Department Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 9%_ Z Igo 1. Permit Requested By A., L Business Phone 2. Address / 4c%a.. 4 C Z Iva� 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy Conventional &-f' Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House +-- Mobile 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 Rooms -3 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 y�l lavatory showers washing machines el dishwasher Nis sinks 8. a) Type water supply: Public ✓ Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions— b) imensions 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. 7 0"4 Date Own/� Signa re OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH L STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: Aaicww-j V 6r . 1 f 1 DCHD(6-82) ov DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a S�a�n/iittary Sewage Systems D Permit 6848 +Number e Name-�6 �! I-< - G ,[J �7(�i� Date �"' N2. O 8 4 O Location &V Subdivision Name Z" jl w e, lel Lot No. Sec. or Block No. Lot Size 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 ❑ Auto Wash Ma shine 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 Tubject to revocation if site plans or the intended use change. �t�i r^ f Qc d b � 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 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 taken as a guarantee that the system will function satisfactorily for any given period of time. t:✓tvf ,-.c r'v!-�k"r:w:v-:r,.atiyg r•suwltwy's vir�..a 4.rsc.a.^"�+:"P...+----w-v vow"'s5-sw.+trwi ,{lY 00A-0 DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE.Issued in�Ceompliance With Article I I of G.S.Chapter 130a 441./ aryZ '/wage VmG ,� /� .�Cyi/ //'92 PerOmit6 8 4.8rName Date Location _ Subdivision Name ""/{� " 4V ��f f Lot No. Sec. or Block No. Lot Size House Mobile Home _� Business Speculation No. Bedrooms .No. Baths 'S No. in Family Garbage Disposal YES NO E] Specifications for System: Auto Dish Washer YES NO ❑ Auto Wash Ma thine YES NO ❑ Type Water Supply 6 *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to re�iocation if site plans or the intended use change. II � �. }} �►� 1 0 b . �gd Ys 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 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 taken as a guarantee that the system will function satisfactorily for Any given period of time. • »-:..,. ry;a .. �•... . , s :e jR . DAVIE COUNTY HEALTH DEPARTMENT r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a Sanitary Sewage Sys ems Permit Number' Name� G��S ,ew'I '05 / Date �`��'�127� N2 6848 Location �'— ) ..'lr`/ y e Oma✓ �G/_ � Oy-' `Irk, �/�/'• �fi �,�' Subdivision Name 11 f��'�✓ ffl���! Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business _— Speculation No. Bedrooms IT -.No. Baths No. in Family Garbage Disposal YES NO ❑ Specifications for System: Auto Dish Washer YES NO ❑ Auto Wash Ma:hive YES NO ❑ Type Water Supply �LS __— '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. .1 �ll0 I i' I 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_ 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 taken as a guarantee that the system will function satisfactorily for any given period of time. y� II 9f tit • y �Y'�.r+. {{ oy }� A� �" '` "�s*{,.r� � JTM,RG 4,ef2 ,, n .,,�•'k�:��T 'bt�� f�"�FY $':ry�d n*•tF` we hi`,i L'.t�aw,' �yYAr � �u���Y . ' "'T ''�4� •�tC" rr7s � =� �• �. .3 ,��, � @`� � �� „�` "''�yyy fir ! �;it_..J',�'x r Zvi t z + •-j 't• .`FJ .,.' ` fe'fir Jtit— `f cb+�rw� k'4k' ;1? '37y{l�ti s,tr a 4-' , 'fft fyy.�r.�1 11�• © xT ( �t��s�:. "t� Aw 11k�.? +a 5} '�S gf �f �* '!•F,R ,Z"�. i. $� R yy4� 'a w�'R • �!$: ,8 {7.��, s Fw.:Ry f' *. raZ•..�`' .-�` y .. '{�:.' ty r A}`�.; y• l t `'1-; �i wit .�+"�� .f� /,��� � r '. �`".t.., 4+." 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