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1648 County Line Rd (2) DAVIE COUNTY HEALTH DEPARTMENT C> 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 E '� ��! /f .. l�l Date ,f /i ,` )`t- Location r y f �� i t''� /f�%_ ,�'< '/ _j J �/ -/ _ - !•✓'` . . � Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home Business Speculation No. Bedrooms No. Baths `T� No. in Family _ Garbage Disposal YES ❑ NO Ej— Specifications for System: Auto Dish Washer YES ❑ NO ❑ " Auto Wash Machine YES j NO ❑ i;' d' LL Type Water Supply *This permit Void if sewage system described below is not installed within 36 months from date of issue. 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 3X/CIL h �`� ��Vrr� tJ �' t �T 3� F . Certificate of Completion�a� �/ 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 �� Q►Q Environmental Health Section C P. O. Box 665 V0 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone q4,�2-5/69 1. Permit Requested By Business Phone 2. Address �"- I boe A-301ry 3. Property Owner if Different than Above I Address 9,'• 1 60X .30 k4Qrmnnu nci C. 063' 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 Homed Business Industry Other b) Number of people Z 6. a) If house or mobile home, state size of'home and number of rooms. House Dimensions ' � ' � ����,�� X 7� Bed Rooms—Bath RoomsJ �� ,, 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 `'L urinals garbage disposal lavatory showers washing machine dishwasher sinks 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yesl No 9. a) Property Dimensions 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? No What type? This is to certify that the information is correct to the best of my knowledge. /0 /Qg-/ ' iv,-' Date O ner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: (04 C-b 9 o 9A rr;AG,S -�b Cow-\+� Lk rz_ 1�cxcl 4"'\ dr-j V e.vJC,,_S or ,c H CSS o,--\ C�v�►, I_i nQ t�oa� DCHD(6-82) W 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_ E)1urn 1Ck , 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. . © 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. .3. Z DATE I SIGNATIJIhE 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 _V_ Only those listed below 1 J do PQln-_7c, h n�Ka.fon aum !s eek 3-1�-g7 .0 DATE SIGNA URE DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION 7 Name Date �����✓ Address Lot Size C FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S NP ) PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) PS PS PS PS U U U 3) Soil Structure (12-36 in.) S S S Clayey SoilsPS PS PS PS U U U 4) Soil Depth (inches) S S S S PS PS PS U U U 5) Soil Drainage: Internal S S S dp PS PS PS U U U U External � ,, S S S (t) PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S S S S 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 - U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title /v Date SITE DIAGRAM 1 � DCHD(6-82) f