P3334 Ijames Church Rd 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 �2 srl'1' llx wiz iotJ Date —7= Y� �'�i� w, .2A
Location 1219f /J l� T.i i4sr�.S Cff• lC U„ L i, ;
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ '"i� Business Speculation
No. Bedrooms _ No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System: 000 ,��n '4-4
Auto Dish Washer YES ❑ NO ❑ i (�
Auto Wash Machine YES ❑ NO ❑
Type Water Supply el� °£-
*This permit Void if sewage systerp-de cr bei d below is not installed within 36 months from date of issue.
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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: System Installed byr, ff
L� (1 2- r �
Certificate of Completion �` f �'"
Date
*The signing of this certificate shall indicate that the system descri_beld above hasbeen installed in compliance with
the standards set forth in the above regulation, but shall in NO way betaken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
`. SOIL/SITE EVALUATION
Name.N° �/W d. Date
Address 'a 2 Z Lot Size
/ylOc is t�/ic L� 1VG Z 702y g
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) (9 PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils & PS PS PS
U U U U
4) Soil Depth (inches) y S S S S
S PS PS PS
U U U U
5) Soil Drainage: Internal ® S S S
PS PS PS PS
U U U U
External a S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S. S S
P 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 Suita
Recommendations/Comments:
✓ �c� a �Nt Gr�7�u+�
Described by .SPS-S Title `� i7A AJ Date
SITE DIAGRAM
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone(_TA)63q
1. Permit Requested By 9rh.P n . F a p Business Phone
2. Address ;) 10
3. Property Owner if Different than Above o_-!1 /?'/� { r�P-•�
Address
4. Permit To: a) Installer Alter Repair
b) Privy Conventional JiL Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
Industry Other
b) Number of people Q
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 1 IS) X 55
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 I urinals garbage disposal
lavatory A showers washing machine
dishwasher sinks ti
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensions Igs )( aSb
b) Land area designated to building site • 7�'d e5v
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 Slg6ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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M16 16.821
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
LOCATION OF PROPERTY: / DATE RECEIVED
•✓p2.f.dJl ,a/�� �. F� �� `�,' �p A 6 ,'7610 (office use only)
yes no (1.) I am the owner of the above described property.
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yes no (2.) I am not the owner of the above described property, haaever, I
j certify that I have consent from mom , ,owner
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cwnek Is nam 6u).,�
obtain a site evaluation by the Health Department for the purpose
of determining the suitability for a ground absorption sewage *;
disposal system.
yes no (3.) I hereby give consent to the authorized representative of the
I� Davie County Health Department to enter upon the above described
property and conduct all testing procedures necessary to
determine its suitability for a ground absorption sewage
disposal system.
DATE SIGNATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
(Owner QUZY
Owner's designated representative
Anyone requesting results
DATE Only those listed below
SIGNATURE
a