512 County Line Rd c s, a--,r" ..:v. -•+i:..+e.rr�sav+ ;4s.-...:<.t.;._ � -.. �..__.+1 .:k. ::, .-_. .. ... .y.:.
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND 'CERTIFICATE OF COMPLETION
*NOTE: Issued. inCompliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage.Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ��rccm e." E e w � Date 2 " O ' $�{ N2 5712
Location � n X so E». �cc��N y �� . `� (oat}
Ql Iv �� CT:. -.,_rE .-rte . 1 `�,
;�
SuRivision Name s v~ Lot No. Sec. or Block No. `�
Lot Size House Mobile Home JC Business Speculation
No. Bedrooms No.,Baths No. in Family 21
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer) YES ❑ NO �/ 0 00
Auto Wash Machine YES [E NO p II
0
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
JB
Improvements permit
*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: System Installed by e Frn-c-- jesU.lLe-
Certificate of Completion `-a N\('A Date /a ' 22- qy
*The signing of this certificate shall indicate that the system describA 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 MEMO 4,i
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requesi By -S /S Business Phone '.�/7IPi
2. Address P14- 3�v , 3
3. Property Owner if Different than Above
Address
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 Home4GBusiness
Industry Other
b) Number of people f
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions 1Y 6,0 /
Bed Rooms._Bath Rooms—Den w/Closet,�/
b) If Business, Industry or Other, State: Number of persons served /v
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals&P'0YL garbage disposal
lavatory 1 showers washing machine
dishwasher AO'Ne sinks l
8. a) Type water supply: Public Private Community
b) Has the water supply system been ap roved? Yes,V-*'No
9. a) Property Dimensions
b) Land area designated to building site Q
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 gighature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: ,
DCHD(6-82)
,f
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �A� �� � � � � � LS Date
Address Lot Size d �►
FACTORS AR 1 ARE02 ARE 3 AR
1) Topography/Landscape Position S S S S
PS-11 <�M lc-� PS
U U U
2) Soil Texture (12-36 in.) Sandy, - PS
Loamy, Clayey, (note 2:1 Clay)
U U U
3) Soil Structure (12-36 in.) S
Clayey Soils C p P PS
lT U U
4) Soil Depth (inches) P � S S
PS
U U U
5) Soil Drainage: Internal S S
di PS
U U � U
External S S
(Jsc P PS
U
U � U
6) Restrictive Horizons
7) Available Space S
PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification S �'
U—UNSUITABLE S—SUITABLE PSrovi 'onaliy Suitable
Recommendations/Comm
Described by i Date .30 S7
SITE DIAGRAM
s1� �
DCHD(6-82)
J..
y fw
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': 7t.t,Ce� DATE RECEIVED
Yq p j o nl (U� (office use only)
133
`es no 1. I 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 , 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.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation resul from the above described property to the following:
Owner only
Owners designated representative
Anyone requesting results
Only those listed below
C s -
DATE SIGNATURE
DCHD(11/84)