4418 Hwy 801S DAVIE COUNTY HEALTH DEPARTMENT' .
w1 IMPROVEMENTS PERMIT AND-CERTIFICATE OF- COMPLETION
`NOTE: Issued in Compliance with G.S. of- North Carolina Chapter-130Article •13c
Sewage Treatme6t and Disposal Rules (1.0 NCAC 10A .1934-.1968.) Permit Number.
Name � - ,., . ,u; Date �— : �
Location
.. j�l �\ J ` - ,.f-Y ry � •-.- `r'R`•+ C� �. - `.'�J'} ; �:4^_i:'a1.r."A `..40
SubdiJision Name Lot No. Sec. or Block No.
Lot :Size House; ,Mobile Home kool Business Speculation
No. Bedrooms No. Baths _ No. in Family
Garbage Disposal YES p' NO [ Specifications for System:
Auto Dish Washer YES V NO .❑ o . , =
Auto Wash Machine YES NO, ❑ ^^d �t''�x.
Type Water,Supply K7
"This permit Void if sewage system de'sc'ribed .below is not.installed,within 36 months from date of issue.
s. 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: Tel a Number: 704-634-5985.
Final Installation Diagram:
PSyteInstalled by
Certificate of Completion Date
'The signing of this certificate shall indicate that the system des cribed,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
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone —�9E- 7/3-9
1. Permit Requested By ��� i ��' Business Phone
2. Address f 6 ow A C.
3. Property Owner if Different than Above S
Address /ems 2 �ox n�e NC .
4. Permit To: a) Install Alter Repair
b) Privy Conventional ether Type
Ground Absorption
c) Sub-Division Sec. Lot No
5. System used to serve what type facility: House 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 /b( 20
Bed Rooms Z Bath Rooms Den w/Closet t
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 Z urinals garbage disposal
lavatory 2 showers Z washing machine /
dishwasher sinks !
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions LC c r e s
b) Land area designated to building site a C- r P_
C) Sewage Disposal Contractor
10. Do you anticipate any,ad itions or//expansions of the facility this sewage system is intended to serve?& �eS
What type? I?v, 0 14F
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:
JWY 6, 5t -gyp �Of SoLtI% Oh
a 9 e- a _{ r "- Ss -r,e l d
Cso L..t.t, e h ,, e d s ..��
DCHD(6-82)
y
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 d/escribed property, however, I certify that I
have consent from s,� � , 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.
es 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 fora 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
7 Owners designated representative
—Anyone requesting results
— Only those listed below
DATE SIGNATURE r
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION L( Q
NameDate
Address Lot Size
FACTORS AREA AREA AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils S PS PS
U U U U
4) Soil Depth (inches) S S
PS PS
U U U U
5) Soil Drainage: Internal S S S
P <IDN PS PS
U U U
External S S
P < J PS PS
U U U U
6) Restrictive Horizons
7) Available Space CC) S S
PS PS PS PS
U U U U
8) Other (Specify) S S . S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS- rovisionaliy Suitable
Recommendations/Comments:
Described by IZ-- Titley Date
SITE DIAGRAM
DCHD(8-82)