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168 McDaniel Road Lot 8DAVIE COUNTY HEALTH DEPARTMENT ,� sf =• '5 -'IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ~i r *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a Sanitary Sewage Systems Permit Number Name /l;t r� _f f /�'� w' -r � ,, /� %1%, :�/r Date ? ��/i�'i 0 t? Location Subdivision Name Lot No. L Sec. or Block No. Lot Size House y''�r Mobile Home _ Business _— Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO p" Specifications for System: Auto Dish Washer YES4 NO ❑ %�� �/� �;t�^ f' �� Auto Wash Machine YES [1] NO ❑ f r f 5 1/1 Type Water Supply r '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. !-" 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 /Y14",1/T/ __ Date �% -f� " r&' *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 X�C611/6'b Davie County Health Department Environmental Health Section J'/9- 90 P. 0. Box 665 Mockaville, NC 27028 1. Application/Permit Requested By �CI.Y b l 1 i'lG _ ��- �% • I"�u �� h Mailing Address _6 . &O �b , : Iv L Home Phone Business Phone 2. Name on Permit if Different than Above {� f,, 3. Property Owner if Different than Above I'i �I.� re `s IBJ ) �n 4. Application/Permit For: LC) General Evaluation &/S/Tank Installation 5. System to Serve: [}House J Mobile Home 0 Business 0 Industry u Other 0 Unknown 6. If house, mobile home: Subdivision -The- P64 (Qkt Sec. Lot# 1 � No. of People Dwelling Dimensions No. of Bedrooms 13 - Basement/Plumbing No. of Bathrooms 01 ` Basement/No Plumbing (Washing Machine VDishwasher 0 Garbage Disposai 7. If business, industry, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Showers No. of Sinks No. of Urinals No. of Water Coolers 8. Type of water supply: Public 0 Private p Community 9. Property Dimensions 10. Sewage Disposal Contractor 11. Do you anticipate additions/ex ansions of the facility this system is intended to serve? 0 Yes PNo 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 plans 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 app cat�on. � (;. ► t �e5, �hf' - l 3 aro v ESUSku' Date --Signature �' o P n C&fi ZQir 1 c -a_ Directions to Property DCHD (10-89) _- V T), e. S 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 LO + —1Y e, Qt S (office use only) o yes no 1. 1 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 fromf� 1,'• 9 GJ Wk 0 , 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 Departmentto enter upon the above described property and conductall testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. 0(arl�li' a 1✓.L 2-13-90 G v -. �,, 0. S DATE SIGNATURE 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 Anyone requesting results Only those listed below Q-13-50 DATE DCHD (11 /84) SI ('6-r o8' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name—RIM iSDate Address Lot Size 120K Vb X 44 3— F ff CA!1T/10Q AREA 1 AREA 9 AREA 3 AREA 4 Topography/ Landscape Position 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) PS PS PS U U U U 1) Soil Structure (12-36 in.) S_ S S S Clayey Soils < - > PS PS PS U U U U l) Soil Depth (inches) S S S S p PS PS PS U U U U i) Soil Drainage: Internal SS S S PS PS PS U U U U External S ®PS S S PS S PS U U U U i) Restrictive Horizons �) Available Space S <=fTx> 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 3) Site Classification U—UNSUITABLE Recommendations/ Comments: S—SUITABLE PS—Provisionally Suitab-16---.,,, Described by'Z".—w Title tl w- RetditY C':'tV— Date ° V SITE DIAGRAM DCHD (6-82) • ' Davie County NealiFr Dye n Aa iii err a d .dome e l y cy 210 HOSPITAL STREET I P.O. BOX 885 MOCKSVILLE, N.C. 27028 PHONE: (704) 834-5985 Potts Realty P. 0. Box 11 Advance, NC 27006 June 22, 1989 Re: Site Evaluation The Poplars -Lot 8 Dear Realtor: On August 14, 1985, as you requested a representative from this office visited the above mentioned site. The soil was found provisionally suitable for the installation of a ground absorption sewage system. If you have any questions, please feel free to contact this office. Sincerely, J Mando, R.S., Director Environmental Health Section JM/wd V Forth Appoo. OMB No. 29004088 isHEALTH AUTHORITY APPROVAL — INDIVIDUAL ��►- Veterans Administration � � . � , ®_ IMPORTANT—This form should be completed and filed as required by existing law 38 U.S.C. 1804 and 1810. PART O BE COMPLETED: MORTGAGEE NAME AND ADDRESS (Include ZIP Code) MORTGAGOR OR SPONSOFI_ PROPERTY ADDRESS:. TOTAL NUMBER THERE A BASE- MENT? YES NO IS THIS A NEW INSTALLATION? []YES 0 NO CAN THE ATTIC OR OTHER AREA BE MADE INTO BEDROOMS?IS ADDITIONAL OYES ONO WATER SUPPLY BY: COMMUNITY SYSTEM Ca"PUBLIC SYSTEM INDIVIDUAL SYSTEM DESIGNED FOR ■ ■ P! ©1. ■ PART O BE COMPLETED: OR COMPLIANCE INSPECTOR ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ ■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■■ it is the opinion of the ■ State ►. ■ ■ Is not satisfactory as a domestic water supply for the subject property. It b the opinion of the ■ State i ■ Local Department satisfactorily, and is not likely to create unsanitary conditions■cannot be expected to function satisfactorily. The health authority should complete the appropriate opinion statement above and affix date, signature and title in the spaces provided. NOTE: Use of the reverse of this form is at the option of the health authority. III—TONOTE: PART : COMPLETED BY I have reviewed the foregoing pertinent Inspection Report considered ■. ... ■ ... . ... . ■ acceptablei not acceptable. SECTIONSIGNATURE OF CHIEF APPRAISAL OR DESIGNEE VA FORM 26,6395 EXIAPR STINQ 15TOUKU UP VA 982. WILL 8E USED. runM W"a QFD, MAY 1985