175 Jack Booe Rd.rte -...x..� y.,,.. v-.=•'t L) 2 --`yy . �fw-.;�K . y".:^ �- o a''\',t� .r. - , %r.....J N .. ..Glsz. - ;'l _ ... .'. - .,-.y ��.. .__ ,.-_ t
DAVIE COUNTY HEALTH DEPARTMENT
-
�.,� �:.•� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOSE: 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 J c. �t< �: rr v s � c �` t`\� Date --) u i No 5P I
Location'
.;* o_`� r`� w..lt=jj +o
Subdivisibn Name Lot No., Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths -- No. in Family r=
Garbage Disposal YES ❑ NO
Specifications for System:
Auto Dish Washer YES [r NO
Autash Machine YES R( NO fl + �
Type Wktter Supply
*This permit Void if'sewage system described below is not installed within 36 months from date of issue.
s
t ` \
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 by �aK :,.�rtiTr
o.
e� C
Certificate of Completion
"The signing of this certificate shall indicate that the system described bove has been instal�jin compliance with
the standards set forth in the above regulation, but shall in NO way be ken as a guarantee the e-system will function .
satisfactorily for any given period of time.
ti � '
i
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section RV��,1
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Ghon G3ai67
1. Permit Requested By 4' Pk
Cusinm Phon (.3q-3538
2. Address _ p tet!! eay
3. Property Jo
er if Different than Above�.CL CC1 _A F - IYQ tyc
Address Io MAA- q71)
4. Permit To: a) Install_,__Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Housel Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 00 4.0O()
W") LM.x)
Bed Rooms—Bath Rooms—Den w/Closet YE19
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 4 showers a washing machine
dishwasher I sinks
8. a) Type water supply: Publics Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 1•a QPAPn
b) Land area designated to building site I AC_ ± G(t/v►a –
c) Sewage Disposal Contractor (A Akn7xJr1
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? nC
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: f N � J_ -C.�. �9!.t_
� .92�
. N
off ) 3y-
DCHD(6-82)
4
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
&woo-- _ 13J3 (office use only)
yes 1. 1 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 I
have consent from---0224 'L m 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.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
— Owner only
Qwners designated representative
V Anyone requesting results
Only those listed below
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date – :vb
Address Q` Q- Lot Size
FACTORS AR 1 AREA AREA 3 AREA 4
1) Topography/Landscape Position S S
(:k PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) �C�l PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS4P PS PS
U U U
4) Soil Depth (inches) S S
p
SP PS PS
U U U
5) Soil Drainage: Internal S S
Gam' PS PS PS
U U U
External S S
PS PS
U
U U U
6) Restrictive Horizons
7) Available SpaceS S S
PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE P Provisionally Suitable
Recommendations/Comments:
Described by !7 Title Date l'26
SITE DIAGRAM
l
1
DCHD(6-82)