215 Adams Rd v � DAVIE COUNTY HEALTH DEPARTMENT ''
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
sr r"NOTE:Issued in,Compliance With Article II of G.S.Chapter 130a
- Sanitary Sewage Systems Permit Number
Name Date l N2 5871
Location
-�
Subdivision Name Lot�o. _ Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No, Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO [e
Specifications for System:
Auto Dish Washer YES ❑ NO Eq/ o v
Auto Wash Machine YES ❑ NO [
t�e � U
Ty e Water Supply \ ,��._rc-` �� _
' his permit V id if sewage system described below is not iIsetcl
a-�^'�i�tli�5years from date of issue.
his permit is subject to revocation if site plans or the inte use ch nge.
�Q
W
Impro ement ermit b
M Jrn y �.
*Contact a representative of the Davie County Health Departme t"for fiiPI inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Tele )hor� Numb�o 704-634-5985.
i
Final Installation Diagram: Syste Inst Iled by ��� *�.t . ��'!'`—
Certificate of-Completion `
"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.
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
Mockaville, NC6627028 RECEIVED FEB p B
1 . Application/Permit Requested By C,44,,V ,Q4
Mailing Address _ �`. }( .�"d�I �GkSdiIle- IQ,6 c77d-�2 R
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : 0 General Evaluation S/Tank Installation
" 5. System to Serve: 0 House Mobile Home Business
0 Industry u Other Unknown
6. If house, mobile home: Subdivision Sec. Lott
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms . _ Basement/No -Plumbing
0 Washing Machine (J' Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes % No. of Urinals
No. of Lavatories / No. of Water Coolers
No. of Showers
8. Type of water supply : Public ' 0 Private 0 Community
9. Property Dimensions /70 >C SCUD
10 Sewage Disposal Contractor i(.Ltf g So&I
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes . No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of -5
years from date issued. Improvements Permits are subject
to. revocation, if site plans or the intended use change .
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from .this applica ion.
/ Date Signature
(7)
//i/6 C170/ c d15x/ ,Le
Dire^t:'J.on� to Property
4 �O
DCHD (10-89)
r l
i
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION COED
RE
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
+OCATION OF PROPERTY: /Pd //'s/ DATE RECEIVED
" " "�w (office use only)
yes 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.
aADATE 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
Owners designated representative
—Anyone requesting results
Only those listed below
ATE SIGNA U E
DCHD(11/84) .
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name o �''' � Date y U
Address Size k �
FACTORS AR!Q l AR A 2 AR 03 AREA 4
1) Topography/Landscape Position S S
S PS S PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) PS PS
U
U U
3) Soil Structure (12-36 in.) ,S S
Clayey Soils PS P PS
U U
4) Soil Depth (inches) S S
p cPS) g PS
�' U U
5) Soil Drainage: Internal S
p PSS PS
U U
External S d\ S
PS
U
U U U
6) Restrictive Horizons
7) Available Space PS 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 S �
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: "-A
Described by Title • S Date
SITE DIAGRAM
16 3
O
DCHD(6.82)