156 McDaniel Road Lot 70,!
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a '
anitary Sewage Systems Permit Number
Name % ' �, lr'� . ! /�=� �� /k �. Z yV'Date �!"/�/ ,.� NO 513 7 5
Location �i , �'/, rr% '~ ,/,� �- i /%/ r'r✓rd'- %.? r
Subdivision Name Lot No. Sec. or Block No.
Lot Size - la, C' House ;rte Mobile Home — Business Speculation
No. Bedrooms— No. Baths �� No. in Family__
Garbage Disposal
YES
NO
❑
Auto Dish Washer
YES
NO
❑
Auto Wash Machine
YES
NO
❑
Type Water Supply
Specifications for System:
G
*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.
Iv,fs
t
Improvements permit by 'l
*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--� 6 r tr.
L �
'4
1
/
Certificate of Completion %' Date &)/M&
*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department q% 19'J�
Environmental Health Section �VED MAR
Mocksville, NC27028R�C�
1. Application/Permit Requested By ;0- rC�
Mailing Address'Sl� SO`j ! tQ Vl S7LC.V'S C a��d�
Home . Phone 650-1 n-3 Business Phone
2 . Name on Permit if Different than Above SCt ►'�'� e
3. Property Owner if Different than Above 7er-r t/ .L�vSs
4. Application/Permit For: General Evaluation @/S/Tank Installation
5. System to Serve: House J Mobile Home Q Business
Industry u Other 0 Unknown
6. If house, mobile home: Subdivision-?oPIa,,S Sec. Lots %
No. of People o2 Dwelling Dimensions
No. of Bedrooms 3 T"Basement/Plumbing
No. of Bathrooms a Basement/No Plumbing
VWashing Machine13-tishwasher garbage Disposai
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: V Public 0 Private @--C-Ommunity
9. Property Dimensions _� l0 ,X y,53 .X 2,2 W I/ -3S off, l cf Acre .5
10. Sewage Disposal Contractor Y)
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? C Yes 9--<0
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 plane 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.
Date
Signature
Directions to Property:
bC-Y
5
DCHD (10-89)
/S F� L)J e 's --E J. ,P ; c' h-� o V-)
o -,-n C (.3 r n Of O e r �c)
aYli e, cd. (S 9, 1%02 Q
j� a(�'.mor 1?cJ
J
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
/--7-,0-7 'r'he (office use only)
Alt D
yes r1 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/ C- - ' , 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.
Oes 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.
.Z•28 -2D — / �� /--, ;1," —
DATE GNATURE
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
hnyone requesting results
LA my those listed below
12 e2 Z/
-z 9� r
2 ��
DATE (GNATURE
DCHD (11 /84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
c
FACTORS AREA 1 AREA ? AREA 3 ARFA A
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
!) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification I
i
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
Title
Date
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Q AS Date g - 14 19'57
Address Lot Size Laa' X '400
CAt�-r^00 APPA 1 APPA 9 ARFA R ARFA A
Topography/ Landscape Position
2)
3)
.4)
5)
Ei)
S
S
S
S
PS
PS
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
e�D
PS
PS
PS
U
U
U
U
Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
cr�g>
PS
PS
PS
U
U
U
U
Soil Depth (inches)
S
S
S
S
<�
PS
PS
PS
U
U
U
U
Soil Drainage: Internal
S
S
S
S
<!:7s>PS
PS
PS
U
U
U
U
External
S
S
S
S
_
'LPA'
PS
PS
PS
U
U
U
U
Restrictive Horizons
') Available Space
S
S
PS
S
PS
S
PS
U
U
U
U
3) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
�) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable-------,
Recommendations/ Comments:
Described by L Title gc g" eta Date
SITE DIAGRAM
DCHD (6-82)
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Mi
CcTw- 4