1774 Junction Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION '
*NOTE:Ass4ed in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage a Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name_L t ` � Y;2 , V� - ..S ° )-t N Date I - Z� N2 56931
Location � 1 L' 1,
r� v ��s v��� \x) •�,1() t
Subdivision Name V` Lot No. Sec. or Block No.
Lot Size / 1" House Mobile Home _✓ Business: Speculation
No. Bedrooms •; No. Baths No. in Family `> _
Garbage Disposal YES,;E] NO 0-/ Specifications for System:
Auto Dish Washer . YESNO
❑
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.
Ion
0,
- 1
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
0
a
Certificate of Completion C 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.
t ` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department AUG 1 �$L�
Environmental Health Section Kc5IVEID
P. O. Box 665
(V1 Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN
pISSUED.
Home Phone�D y— '/ 3.2 7
1. Permit Reqt4ested By Business Phone .2S q— 33 3
2. Address w*�7, On 4 2
3. Property Owner if Different than Above �
Address 3O}l �O 7 c L 2? L ZS
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional Z/� Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home V Business x Sd
IndustryOther
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions M441 &
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 washing machine
dishwasher sinks A
8. a) Type water supply: Public_ Private Community
b) Has the water supply system been approved? Yes I/ No
9. a) Property Dimensions 2 lr "
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 correct to the best of my knowledge.
Date Iner Signature
OWNER IS LELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
All 5 da s f proce sing
LDirections to property:
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 PROPERTY: DATE RECEIVED
(office use only)
yes no 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 , 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 results from the above described property to the following:
.1L Owner only
— Owners designated representative
_Anyone requesting results
_ Only those listed below
S�15-89 ,
DATE OSIGNATORE
DCHD(11/84)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��\� �'C� Date 5� r
Address P Lot Size
FACTORS AR A 1 AR6 AR 3 ARE/54
1) Topography/Landscape Position _S_.� S �cp:' �
U j U U
2) Soil Texture (12-36 in.) Sandy, SS
Loamy, Clayey, (note 2:1 Clay) P PS PS GAS
U U
3) Soil Structure (12-36 in.) S S
es)Clayey Soils � S
U U
4) Soil Depth (inches) S S
pS4� � S
U
5) Soil Drainage: Internal � S � �S
U U U
External PS C83
U U U
6) Restrictive Horizons
7) Available Space 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 Qz�> I
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
� _
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
�b�l 6z
� � 1
_0b
DCHD(6-82)