P5289 Howell Rd ti .
} DAVIE COUNTY HEALTH DEPARTMENT
' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*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
i
Name nate N2 5289
Locationi�' .�r� ✓�1 �/,% �— ,/,1 'sP 1 "�.
Subdivision NameL,ot No. Sec. or Block No.
Lot Size IXI /��� House 12,, Mobile Home _ Business Speculation
No. Bedrooms o� No. Baths �Q _ No. in Far mily
Garbage Disposal YES .❑ NO ❑ x' Specificati s for System:
Auto Dish Washer YES ❑ NO ❑ /�G� � ��
Auto Wash Machine YES ❑ NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 mo hs from date of issue.
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Improvements permit by �'�'
*Contact a representative of the Davie Co ty 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 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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department R
Environmental Health Section
R O. Box 665 �C �V - JUL
Mocksville, N.C. 27028 /�,, 0�j G) V a
A/0 ft
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone
1. Permit Requested By a f /r'✓' C Business Phone
2. Address e-:k 2 ao'X /lb3;q- rla r► c e A)- e'_,
3. Property Owner if Different than Above e
Address
4. Permit To: a) Install Alter Repair�
b) Privy ConventionaIL Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business—
Industry—
usiness Industry Other—
b)
ther b) Number of people �3
6. aT If house or mobile home, state size of home and number of rooms.
House Dimensions ��y
Bed Rooms.—Bath Rooms a Den w/Close (D
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 oZ urinals garbage disposal
lavatory showers a washing machine
dishwasher 1 sinks C9-
8. a) Type water supply: Public Privateer Community
b) Has the water supply system been approved? Yes NoZ
9. a) Property Dimensions I- A -rT_-
b) Land area designated to building site
c) Sewage Disposal Contractor
16. 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.
Zg �
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
bra e Al )odst//%Ile -- Alorfh 6od l ter
F G3.�U/7S C�! u.rGl�. /2d aGC —' �'�✓L l�f'1 ��7� dJ'� �lr,�l��.
DCHD(6-62)
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:
'01,0 ell ,QQ/ DATE RECEIVED
s30 �d v C (officeuse only)
- S!-.?;P
yes no 1. I am the owner of the above described property.
es no 2. 1 am not the owner of the above described property, however, I certify that
have consent from A >--.rle,AfC 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.
AT SIGNAT E
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
�Z7�
ATE SIGNATURE
DCHD(11/84)
Qk
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Name � Date
Address Lot Size Ae—
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
e
PS U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) S , P PS
L% U
3) Soil Structure (12-36 in.) S S
Clayey Soils SP (P5/ PS
U
4) Soil Depth (inches) S S S
S PS FS? PS
U
5) Soil Drainage: Internal
S PS ` IPS ? PS
U
External S S S
S (FPS
6) Restrictive Horizonsa�/J,�
7) Available Space S S S
S PS �S PS
U U U
8) Other(Specify) S S S
P PS PS PS
U /�U U
9) Site Classification (� v 51 1
-
U—UNSUITABLE S—SUITAB E PS—Provisionally Suitable
Recommendations/Comments: '" , y,
Described by !^ �� / Title Date
SITE DIAGRAM ,
I
DCHD(5-82)