4670 Hwy 158 A• DAVIE COUNTY HEALTH DEPARTMENT
'IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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- `DOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems t Permit Number
Name r ��,.�' Date � N2 5867
Location k r� /xr
Subdivision Name / Lot No. Sec. or Block No.
Lot SizeHousey Mobile Home _ Business Speculation
No. Bedrooms.. No. Baths No. in Family�—
Garbage Disposal YES [ N0(V Specifications for System:
Auto Dish Washer YES rill",
NO E3 /000
1
Auto Wash Machine YES ['� NO ❑
Type, Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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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.
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Final Installation Diagram: System Installed by ►y ��'1' `h � '
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Certificate of Completion Date -
*The signing of t�is 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
0 , P. 0. Box 665
` Mockoville, NC 27028 RECEIVED FEB 2T
1 . Application/Permit Requested By OrerCk. YX e m i
Mailing Address R+ - 0 . B O X 3) Ad vans a- N ( 2 ?oo&
Home Phone q q q '11C181) Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: lC) General Evaluation VS/Tank Installation
S. System to Serve: House J Mobile Home Business
Industry g.-Other �ara9e ,�,� 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People 1 Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms / �p--- Basement/No Plumbing
Dy' Washing MachineLm-
V Dishwasher (Garbage D:isposai
7. If business, industry, other: Specify type _A-aro la-
No. of People Served No. of Sinks .�
No. of Commodes 1=-�. No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
S. Type of water supply: ublic Private 91 `0mmunity
9. Property Dimensions -__1, 2 c_r�
10. Sewage Disposal Contractor _
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? Yes @Ao
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 tree
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
D�_1 a-) ) 6)0 , 1 � -L� L4.1-W�
'Date Signature
Directions to Property : ,-1
�'GcJ �cJ-H ry i o r e R o coot`• r r,•e r L a f a7--
DCHD (10-89)
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
, 1543 q-,8AANmore.Rd. -d6roer,Co+ (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.
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 for a ground
absorption sewage treatment and disposal system.
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
—AZAnyone requesting results
—Only those listed below
2420
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Namem%�'� Date
Address Lot Size 4g&e
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position lS �S� S
—PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay)
U
3) Soil Structure (12-36 in.) S S S
Clayey Soils //P%
4) Soil Depth (inches) S P
U U U
5) Soil Drainage: Internal S(lS S S
(*P
External
6) Restrictive Horizons _
7) Available Space Ste-,
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U . U
9) Site Classification < 17, A)(—
U—UNSUITABLE S—SUITABLE <�isionally Suitable
Recommendations/Comments: A
Described by Title / Date YlM
SITE DIAGRAM
ky .
DCHD(6-82)