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✓ DAVIE COUNTY HEALTH DEPARTMENT e 3 O
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage,-Treatment and Disposal Rules (10 NCAC 10,4 .1934-.1 68) Permit Number
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Name ate ''
_ ; /� ��• .'�:: 7'1
Location
Subdivision Name Lot No Sec. or Block No.
Lot Size %i House Mobile Home i/ Business Speculation
No. Bedrooms — No. Baths ? No. in Family —
Garbage Disposal YES :0 NO Specifications for System:
Auto Dish Washer YES T NO
Auto Wash Machine YES j NO p �(,�l1r✓�t,.e �'
Type Water Supply
4.
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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-----------
'- Improv ments permit by
,
*Contact a representative of the Davie County Health Department fob 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
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,J Q
Certificate of Completion Date
_ \�'�'��� Date
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.
l �+
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTR CTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone C^3Q/` d ~
1. Permit Requested By C, ���-' i e iQ'C L nl.c S Business Phone
2. Address
3. Property Owner if Different than Above Address -
4.
ddress 4. Permit To: a) Install Alter Repair V
b) Privy Conventional Other Type—
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home B�s
Y YP Y
IndustryOther—
b)
ther b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms 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 a urinals garbage disposal
lavatory showers - washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes 1Z No
9. a) Property Dimensions cQ aP_AAn
b) Land area designated to building site
c) Sewage Disposal Contractor
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 Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: p I f �� WA
✓�-�Cl S-YYL)�L �- CX �
�eC�ti)n'�uf
\DCHD(6-82)
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. 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)
yes 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 m2• u 9 ify)iq nJ , 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 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.
\$� ti
DATE SIGNATUIIE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
O ner only
Owners designated representative
Anyone requesting results
Only those listed below
DATE SIGNATUR5
DCHD(11/84)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
T
SOIL/SITE EVALUATION
Name e Date / � 7
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, s�...c� S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(6-82)
O7
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
n Environmental Health Section
B / P. O. Box 665
,�
�O Mocksville, N.C. 27028
1f1J�1 I> NSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT H S B EN ISSUED.
Hom PFSon
1. Permit ReqIjested By ' Business Phone
2. Address11
3. Property 6144nif Different than Above
Address
4. Permit To: a) Install k:6-A Iter Repair
b) Privy Conventional `Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home!s
IndustryOther
b) Number of people -3
6. a1 If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed RoomsBath Rooms 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 �' urinals garbage disposal
lavatory showers washing machine
dishwasher sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply systema been approved? Yes_k!!f-No
9. a) Property Dimensions—
b)
imensions b) Land area designated to building site
c) Sewage Disposal Contractor "-
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? L-M-0
What type?
This is to certi that the information is correct to the best of my knowledge.
Al!-7,17141
ate Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIA E WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
1-9
DCHD(6-82)