180 Feed Mill Rd .. .. .+?+Yi H.0 r. N'y...:_Fi.,., .vdrrt'..iRYu VM.. 'klNi�:,l., aa.,.�;i.. .r ..,i yd .. s .,.:,5..;: ...pry.t, ..•,` .;.iN.
f DAVIE COUNTY HEALTH DEPARTMENT
IV- 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 Z0. A�i Date -9
G '
Location I ~ / / / I /�/ l l�/ ;d_-.fir y T f
Subdivision Name Lot No. Sec. or Block No.
Lot Size ;'` House Mobile Home _tf Business —_ Speculation
No. Bedrooms L2 No. Baths _�_ No. in Family _
Garbage Disposal YES E] NO [a-' Specifications for S stem: -
P Y
Auto Dish Washer YES NO ". y=`
Auto Wash Machine YES NO /
Type Water Supply ! __
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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 byy
C it Q
u
Certificate of Completion \ "� �� - 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section F?EC'CjVED MAR p
P. O. Box 665 1%7
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. p�
Home PhoneUo
1. Permit Requested By Business Phone '9-e
2. Address -^
3. Property Owner if DiffeyQnt than Above 998- 58a
Address
3
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: House Mobile Home ' Business
Industry Other
b) Number of people I?--
6. a) If house or mobile home, state ize of homF and number of rooms.
House Dimensions
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
8. a) Type water supply: Public Private Copamunity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /1-6-0 X /?
b) Land area designated to building site x
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.
-24
_ C&�
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
r
s�
DCHD(6-82)
a
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. 0. 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 Pe ab a d ropert f, 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 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.
-!2z–P? Lz::�V�- ��
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
— Owners designated representative
Anyone requesting results
— Only those listed below
r
/ 0 i
DATE SI NATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date J
Address - 67 Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) (!SP PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S S
S 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 Suitable
Recommendations/Comments: 'y
Described by � Title �� Date
SITE DIAGRAM
I
1
�I
i
1
DCHD(8-82)