265 Carpenter Ln.,,..,ria..-.e�...e-..-w:t.a.....:�,r+-. . :+:grwv:.W""^'c.+'."'^tiw•-•v<.t...L-'l'-r-.irf:,iss✓..i,+ii.irr'.Fy��.ai1'-.i.+.-.'+r.s-r+;:. ..::w.,^:a:w ::13.�,�.�..3.4rh.. .. s—_,., .r _.. "—
u� DAVIE COUNTY HEALTH DEPARTMENT ,
-, IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIOIrarp1pe
*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 Ai.,?=:�t ti _.s Y^ c> Date —L - �.", `7`i a` n' :3 2 3 5
Location
Subdivision Name `' Lot No. Sec. or Block No
Lot Size, House 1. Mobile Home — Business Speculation
No. BedroomsL/ No. Baths— No. in Family-. —
Garbage Disposal YES p NO ]/ Specifications for System:
Auto Dish Washer YES V NO p , _.. . • �,
Auto Wash Machine YES I-1. NO p
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
I_
\� • `--•'�,r _ Irl �-•,.� �
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: l Sy�eem Installed by
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/l x/. 1:1 11 �+
Ct
erti i ate of ompletion Date
The signing of th�i �certifLtsll in iia, C that he s`stem described above has been installed in compliance with
the standards set forth in the boa re ulat) n, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for angiven�er od f tim�.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS. PERMIT
Davie County Health Department V�
a�� r Environmental Health Section cc GCCD .� Q
R O. Box 665
Mocksville, N.C. 27028 v
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. /
IAIIW_' �44el
Home Phone 7��' w1. Permit Re uested B (� C P�✓yP� Business Phone
2. Address .rr
3. Property Owne if Different than A ve �0L� L d
Address J 1WA4ef ire
4. Permit To: a) Install Alter Repair
b) Privy Conventional !!!�Other Type—
Ground
ype Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home—Business
Industry Other
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House DimensVs sg' X '3�
Bed Rooms-��—Bath Rooms Den w/Close
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 S urinals garbage disposal Q
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private v1 Community
b) Has the water supply system been approved? Yes eNo
9. a) Property Dimensions •- 4-1Z Ae,,&4S
b) Land area designated to building site -r4A---
c) Sewage Disposal Contractor udtAJOWIJ
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.
Date Owngr 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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DAVIE COUNTY HEALTH DEPARTMENT
4 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. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
S1,ore lal, yo .6'rle Caawil
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 from (/1,e&t W -L: 61, eWI'ee , owner to obtain a
o per'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 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.
�8
DATE SIGNATU
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
DATE SIGN URE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section.
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name kIch(Xy-j C+C-1r^ 1c7IZn r Date
Address � ����� Lot Size J^
FACTORS AREA 1 AREA 2 AREA 3 AREA 4 S
1) Topography/Landscape Position SS
lT bu
U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ® PS �PS
U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils ® S PS PS
U
4) Soil Depth (inches) S � PS
U <ib U
5) Soil Drainage: Internal SS S S
S PS
U d5 U
External (t) ® y 0
U U U
6) Restrictive Horizons C ROCK`S
7) Available SpaceS
is S S PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U . U
9) Site Classification S Q—S
Q--1U SUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
S
Described by Title �� _-- `� Date
SITE DIAGRAM
VCHD(6.82)
DAVIE COUNTY HEALTH DEPARTMENT
Y
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION p
Name Date
Address -S Lot Size
S
FACTORS ARE01 ARE AREA(�) AREA
1) Topography/Landscape Position S S S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U U
5) 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
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS _PS
U
9) Site Classification S V J
U—UNSUITABLE S—SUITABLE PS—Provisionali Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(6.82)