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P6597 McClamrock RdDAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND. CERTIFICATE OF COMPLETION 'NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a Sanita rySewage S stems -i---=`% Permit Number Name -r--44ale �Date //t7li-5�/ N2 6597. Location ,lS`�'-G /✓7l�/i iih�.� -/ s // r. �i� ��-� u r- � -- "i Improvements permit by 2ya ' '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: /1 ✓/i!r va9 D' q � odq System Installed by (11� /d0 1 . /'4A 11 61 xis " 3/^� Certhatthe ompletion / _ Date 'The signing of this certificate shat indicate 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. — i Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths— No. in Family . r_ Garbage Disposal YES ❑ NO E Specifications for System: Auto Dish Washer Auto Wash Ma:hine YES NO ❑ YES NO '. f"syr y ❑ �J ^. Type WaterSupply --. �� a '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 u e change. e. a� r Rfr u r- � -- "i Improvements permit by 2ya ' '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: /1 ✓/i!r va9 D' q � odq System Installed by (11� /d0 1 . /'4A 11 61 xis " 3/^� Certhatthe ompletion / _ Date 'The signing of this certificate shat indicate 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 Environmental Health Section R O. Box 665 r Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 1. Permit Requested By Ci9eP\( L• M,- 2. Address (os( W , /iA/17A ST AnOi Home Phone k)*3 C ' 3°(I Co Business Phone 3. Property Owner if Different than Above wlcu hrrLJ • R - SELL e E of Address GGS 0 •A"W YT. /tit��sV GI.0 C, nS C 4. Permit To: a) InstalIX Alter_ Repair— b) Privy_ Conventional Other Type— Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: Housed Mobile Home— Business— Industry— Other— b) Number of people 6. ay If house or mobile home, state size of home and number of rooms. HouseDimensions Bed Rooms Ao� Bath" Rooms D n we /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 41 urinals_ lavatory 4- showers dishwasher t sinks — Z 8. a) Type water supply: Public Private X Community b) Has the water supply system been approved? Yes_ No" 9. a) Property Dimensions 4o 5NCke-_r b) Land area designated to building site 3 p cV2 garbage disposal washing machine c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Wd What type? This is to certify that the information is correct to the best of my knowledge. Date w er Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLI H LL STATE AND LOCAL LAWS Allow 5 days for processi g Directions to property: CAGL MR, AT, R W ILC. S �-(ow 14OU -CkC, S7Z'-& DCHD Je-e2) DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM a 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, R O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED OFP M°cGAffi ogLv�, DCcI�� (office use only) yes (no ) 1. 1 am the owner of the above described property. yes no 2. I am not the owner of the above described property, however, I certify that I have consent from 13�2V� Stu-- ,owner to obtain a .owner's name site evaluation by the Davie County Health Depart ment for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. I hereby give consent to the authorized representative of the Davie County Health Departmentto enter upon the above described propertyand conductall testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. VMIG _ 4. I hereby authorize the Davie Couniy,.kiefalth 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 G Q,4rb4 L . M rc t * M`K..o ctc �4 � r , DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION SITE EVALUATION CONSENT FORM a 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, R O. Box 665, Mocksville, N.C. 27028 Davie County Health Department Environmental Health Section Site Evaluation Consent Form LOCATION OF PROPERTY: DATE RECEIVED OFP M°cGAffi ogLv�, DCcI�� (office use only) yes (no ) 1. 1 am the owner of the above described property. yes no 2. I am not the owner of the above described property, however, I certify that I have consent from 13�2V� Stu-- ,owner to obtain a .owner's name site evaluation by the Davie County Health Depart ment for the purpose of determining the suitability for a ground absorption sewage treatment and disposal system. yes no 3. I hereby give consent to the authorized representative of the Davie County Health Departmentto enter upon the above described propertyand conductall testing procedures as necessary to determine its suitability for a ground absorption sewage treatment and disposal system. VMIG _ 4. I hereby authorize the Davie Couniy,.kiefalth 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 G Q,4rb4 L . M rc t * M`K..o ctc �4 � E pi DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name G',er� oy `�%le C� �nr,eae� Tgz , Date Address—OFF tZ8 (iAA7y1 g d o 4 Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA A 1) Topography/ Landscape Position PS 2) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) S� U 3) Soil Structure (12-36 in.) Clayey Soilsp C S S U U 1) Soil Depth (inches) S S S _ S— i) Soil Drainage: Internal ---�� U U External S &;;� S � S cj i) Restrictive Horizons Available Space PS PS PS S U U U U I) Other (Specify) S PS S PS S PS - S PS U U U 1) Site Classification i U—UNSUITABLE Recommendations/Comments: S—SUITABLE PS—Provisionally Suitable Described by �� Title Date SITE DIAGRAM XI k DCHD (6-82( Y.Z Davie Caunty Neaki l7�§uartment and Nome Jfealt§ ✓lyency 210 HOSPITAL STREET/ P.O. BOX 885 MOCKSVILLE, H.O. 27028 PHONE: (704) 834.5985 September 28, 1989 Grady L. McClamrock, Jr. 651 N. Main St. Mocksville, NC 27028 Re: Site Evaluation Off McClamrock Road Dear Mr. McClamrock: On September 21, 1989, 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, Robert B. Hall, Jr., R.S. Environmental Health Section RH/wd Enclosure c- �. t ;.., ;.., <v . STATEMENT DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION 210 HOSPITAL STREET P. O. BOX 665 MOCKSVILLE, NORTH CAROLINA 27028 (704) 634-5985 DATE 09-28-89 Grady L. McClamrock, Jr. 651 N. Main St. Mocksville, NC 27028 Site Eval./Off McClamrock Rd. - $50.00 L I DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT. 09-28-891 Site Eval./Grady L. McClamrock, Jr. $50.00 Off McClamrock Rd. BALANCE DUE — - STATEMENT DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL_ HEALTH _SECTION 210 HOSPITAL STREET P- O. BOX 665 - - MOCKSVILLE. NORTH CAROLINA 27028 (704) 634-5985 November 20, 1991 Grady 11cCiamrock, Jr. �� ,. ...._ i�•o.,3yc 114.x} Mocksville, KC- 27028 - - -- - Permit 6597 (KcClamrock Rd.) -.550.00 Pay�ent Due w 'Vin730•Days -"-. - .DETACNANDAMALri_YOUR CNECE.,g ,4 FYONR CAMMUD CHECK IS YOUR ---------------------- 11-20-91-I Permit 6597/Grady McClamrock, Jr. 1 $50.00 --------------------------------------- w i ---------*-------------------------------------------- � 1 ---------------------------------------------------- ------------ "�eep C''P`,----------------------------------- 1 1 1--------------------------- ----------------- ------------- --:- -----GQ--� - ----------------- ----------------------- --------------- - 1. ---------------- -- -------.-------- ( -p199E-- -- i ---------------------- - -- --------- i i 1. ---------------------- -- ----------------=--------=----- -------------------------------------------------------------- I . . HALARCE DUE - 1 '550.00