136 Marchmont Dr Lot 19 DAVIE COUNTY HEALTW DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIONwro/v
*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 ( sl�'�" 1,7✓ ,✓'G�l'/, ' �//Vii% �.,,.spate ✓i N2 .��L6.
ri:✓ 7
Location �� /-'s /•�.f .tel/— /��,�ri�<i%�i,�: /
Subdivision Name Lot No. Sec. or Block No.
Lot Size C"� i'/1� House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family -
Garbage Disposal YES 1P NO p Specifications for System:
Auto Dish Washer YES Ep NO p /4 C
Auto Wash Machine YES
Type Water Supply __ %ice:%�.3 ✓=y
*This permit Void if sewage system described below is not installed within 36 months from date f issue.
\A
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 b����4 16-11L�/tea-.i�
r ,
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
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
� Home PVo14- 76 6 �2-
1
1. Permit Requ ted By C-���� /�`; Business Phone — -m-=
2. Address
-r
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division�AUI-4in,---tSec. Lot No.�
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. aT If house or mobile home, state size of home and number of rooms.
House Dimensions '1710 r 3 2—
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 3 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? Yes No
9. a) Property Dimensions gi g -
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? 40
What type?
This is to certify that the information is correct to the best of
my knowledge.
Dae Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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
n 1pz'j; 4�— ( 9 (office use only)
es 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 I , 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 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.
TE 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
DATE SIGNATURE
DCHD(11/84)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT vo
Davie County Health Department
Environmental Health Section
P. O. Box 665 -
I,I Mocksville, N.C. 27028 '
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone�� D
1. Permit Re sledRl Business Phone R
2. Address
3. Property Owner if Different than Above __
Address
L . d`QrJ� w,-a. 'II-nm SAI{pm . A-(2 , 9,,)11'5'
4. Permit To: a) InstalliZAlter Repair
b) Privy Conventional Other Type—
Gro f�o�l oiv
GrM , q�sor '( 1 / '�kkt /
��l �,/ o P /�/gNl/k�bJ
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
Bed Rooms Bath Rooms <0 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 Community
b) Has the water supply system been approved? Yes_ZNo
9. a) Property Dimensions Oell X 305 .2 �23.
b) Land area designated to building site Al-
c) Sewage Disposal Contractor meg
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 6
What type?
This is to certify that the information 's c rect to the est of rqy kno ledge.
0Date O ne ig ature
OWNER IS SOLELY RESPONSIBLE FOR CO LIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD( -82) 20 p/e 1pC�O �OCY/�O USG /Lie ��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: )—o+ )9 .1t4 DATE RECEIVED
MArJM0,U+P1 A 41-'D/U A;r 1 ArK LuW (office use only)
1J ( y� omRia,4 ur
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above described pro rt however, I certify that I
have consent from�A )'-M UA4 01 , 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 propertyand conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATEI ATURE
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
X Only those listed below
Isy, VIP
mysp
I- IV 0
DATE 44s,�idNATOR-Er
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date o2l;2
Address Lot Size 42 6�E
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionrS�., S S S
P I PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) A) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U 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 PS
U U U
External S S S
PS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space 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
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
1
Recommendations/Comments:
Described by Title ./tel Date 4h:?I&
SITE DIAGRAM
DCHD(6.82)