129 Jackson Dr Lot 6 Section 2i
LOCATION OF PROPERTY:
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
DATE RECEIVED
(office use only)
S-/-7�
yes no (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described prope.ty, however, I
0I� certify that I have consent from CSI, -1- ,owner to
1 owner's name
obtain a site evaluation by the Health Department for the purpose
of determining the suitability for a ground absorption sewage
disposal systems.
yes (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.
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— � Cl dQ. 7
DATE S NAT RE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
C Owner Only
Owner's designated representative
( Anyone requesting results
0-lonly those listed below
91f -�3
DAVIL COUNTY HEALTH DEPARVIENT
PERCOLATION TEST RESULTS
DATE 1 1
NAIME Mr. A. J. Lawrence Rt. 3, Box 220 A Mocksville Tel: 998-2322
LOCATIOLI Greenwood Lakes Lot # 6, Block 8
FINDINGS:
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HOLE 140.
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6
COMMEATS
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LOT DIAGRAM / 1 � � �� � bat
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APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 7416 - `f a-7 0
1. Permit Requested By �-�R21GS-Ue1Ancy Business Phone 773" 1 �� f
2. Address 110-114 a -K Cl e w w, --i - Z7 12
3. Property Owner if Different than Above S C C Q `^^CS k 1 C1
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional "- Other Type
Ground Absorption
c) Sub -Division FREE"w°u�</`j 3ec.— Lot No.
5. System used to serve what type facility: House v Mobile Home Business
`f IndustryOther
b) Number of people 'T
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms �i� 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 3 urinals
lavatory 3 showers Z -
garbage disposal N `�
washing machine v
dishwasher 1 sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 24o3 ` x (7 I'S X 179'b X
b) Land area designated to building site
c) Sewage Disposal Contractor u
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.
it 4
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82)
Pulaie TauntU Pealth Department
nub pume pealth �Brnry
P. O. BOX 665
Aarksbille, �Kurtli Carolina 27028
OFFICE OF THE DIRECTOR
February 14, 1984
Mr. Charles Delaney
P.O. Box 274
Clemmons, N.C. 27102
Re: Greenwood Lakes, Lot #6, Block 8
Davie County
Mr, Delaney:
The lot mentioned above was evaluated by this office on May 8, 1979.
At that time the lot was classified as provisionally suitable for the
installation of a ground absorption sewage treatment and disposal system.
Upon your request a revisit was made to the property on January 30, 1984.
As was the case during the 1979 evaluation this last evaluation proved to
be the same classification.
As I explained on the site January 30, 1984 this office stands ready
to issue the required Improvements Permit for the sewage treatment and
disposal system upon your request. Assuming that the conditions will not
change on the property from now until the time you are ready to start the
construction of your home this office can see no problems with issuing the
permit.
Should this office be of further assistance concerning this matter
please advise.
'ncerely,
e Mando, R.S.
Env. Health Coordinator
TELEPHONE
17041 834.5985