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119 Gordon Dr (2) 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' Name ? t\N Q' tom` Date I U - % - r: djr7 Location �� . L V A �..._� 6`t�.- '�_ �?+�lL �'1 � t3.- �� .t-. �`• al N._ �1_ l asi 7ti , w.E'_ Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ `� Business Speculation No. Bedrooms r� No. Baths �1F No. in Family .- _ Garbage Disposal YES E) NO Q* Specifications for System: Auto Dish Washer . YES ❑ NO Auto Wash Machine YES [y NO p C)�� 0 x ` 1 Type Water Supply C ,3'C --- 0 *This permit Void if sewage system described below is not installed within 36 months from date of issue. 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 Di rame System Installed by G tP t� too 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. ir,»;,,..,I.,. ''+`..s..`:.,.6y+;::r.:•.r�K.F Y��+.e.�r we>h.ri:.r-Ma�+.W-,:..:. '..�:1w.,%fiv.w=,::i�J:-i� "-"-+^^`."."�"'�.`'`'°'""i"t"c`°"'.;.�-w+•.4ei-.�..yr...-�.. ..+..-. .-_ ...,.-. ... ,,�.,,. DAVIE COUNTY HEALTH DEPARTMENT - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NATE: r`ssued 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 �,. Date U _ r 194 7 Location '`, N %j t=\ t Subdivision Name Lot No. Sec. or Block No. Lot Size ? —�r,0 House Mobile Home _ ""� Business Speculation No. Bedrooms Y ) No. Baths `.�� No. in Family Garbage Disposal YES E] NO Specifications for System: Auto Dish Washer YES E] NO Auto Wash Machine YES NO'p Type Water Supply __— *This permit Void if sewage system described below is not installed within 36 months from date of issue. t ✓, r i 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 Dia lgrame) System Installed by L Certificate'of Completion ` '�� - Date I �' *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. VOU w APPLICATION*FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department 6 Environmental Health Section 0 2 P. O. Box 665 RECEIVED O C Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone �/_7�/7 1. Permit Requested B7 Business Phone 2. Address 3. Property Owner if Different than Above Address /�� 33-�19_ d, 4. Permit To: a) Install-ZAlter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Homes Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 11/70 Bed Rooms 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 urinals garbage disposal .� lavatory showers I washing machine dishwasher D sinks i 8. a) Type water supply: Public Private CoJnmunity b) Has the water supply system been approved? Yes ,/ No 9. a) Property Dimensions Ox_ao d 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 corre t to the b t of m knowledge. C7 3o — Date Owner Signatur OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: � ' � f��ry.� ort ��" Ldp �s 2=�� -�G✓� 12,0� , Qs y�� 7aR12 "U 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 P OPERTY: r DATE RECEIVED t�us� Meda-��( �o Gv,-dog✓ Qr� vL� �, ht ani (office use only) Gd oisJ �POr�YG 0►v Vii, /,,7L i) OF- 43 4S YIJLt - (Urrtl /n/ yesno 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 sy ��l , owner to obtain a own is 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. DATE S GNATURE 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 SIGNA RE DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. - P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name t Date AddressLot Size FACTORS AREC ARE&2 AREA 3 AREA 4 1) Topography/Landscape Position S — S S (::r� PS PS U U U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) !1 P ,<�& PS PS U U U U 3) Soil Structure (12-36 in.) �5 S S Clayey Soils A3j PS PS U U U U 4) Soil Depth (inches) S S PS � PS PS U U 5) Soil Drainage: Internal S S S PS PS U U U U External t) S S p PS PS U U U U 6) Restrictive Horizons - 1n ✓ 7) Available Space S S PS PS PS U U 8) Other (Specify) S S S S PS PS PS PS U U . U 9) Site Classification U—UNSUITABLE S—SUITABLE —Provisionally Suitable Recommendations/Comments: Described by — Title �� Date 6- -B — SITE DIAGRAM ba DCHD(6-82) t �5 '. ''r �� Ati