143 Camellia Ln DAVIE COUNTY HEALTH DEPARTMENT
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 "` � ./':0=. . , Date —fir' %� _ 363
Location /^�''/�'7�'_ r:r�1��3 •'r/� .; � :.;-r Vii. .F, ref ✓' ` /<�.
+
Subdivision Name Lot No. Sec. or Block No.
Lot Size -A I/ r House Mobile Home _�'' Business Speculation
No. Bedrooms �'� No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑
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 by
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Certificate of Completion � Date 14 -d
*The signing of this certificate shall indicate that the system described Love 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.
7-Ig
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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 Pho4io-3)'�ec-7r?,Re 95-
1. Permit Requested Byn -f�• `a' F� �' �S f.7o l�-Sn✓cam, ,�P� Business Phone
2. Address /� U-d//OL�JC�u �!' �un��� S.� . -2
3. Property Owner if Different than Above 10a4-el- //" 777
AddressJ� f 3,) y //41-3, Meek Dille, /' c
4. Permit To: a) Install_L✓Alter Repair
" �b .Privy Conventional_re Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home ✓Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Zy�X 70
Bed Rooms— o� 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—kf- Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 7•d.r S a/ X • 6 / ��S /
b) Land area designated to building site a D D �,X /66 6 `� ,X Z Z.4.6
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? r-
What type?
This is to certify that the information is correct to the best of my knowledge.
7 � -
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
HAIr6 o / 41, lo �2a�e�- �o�• - 2f Drt �D�9.t�rt�E� b _(Ta �5�m %
G4 larnL � le-P ^ Mr . V0,074-5.aV0,074-5.�- eyPs �',,� n �. �
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2. Along with the form, remit the amount due as shown on enclosed statement.
3. Carefully follow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARTMENT,P.O. BOX 57)
(MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPART10NT
SITE EVALUATION CONSENT rom
LOCATION OF PROPERTY: DATE RECEIVED
d F r— 17 Q-h d e /- Pd G (office use only)
� t>�T' �4T� �STi(nic� f/ouSe �rrST
Mo h, -r 6 Al P 7
yes not (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described property, however, I
certify that I have consent from ,owner to
owner's name
obtain a site evaluation by the Health Department for the purpose
of determining the suitability for a ground absorption sewage
disposal system.
yes no (3.) I 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 necessary to
determine its suitability for a ground absorption sewage
disposal system.
DATE SIGNATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
Owner Only
�` / 7 M oysmer's designated representative
/ Anyone requesting results
DATE Only those listed below
f. Ir`—..___.___.,
CLL.' .', ., =
SIGNATURE
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S S
cvp PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ® PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils P 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 S
PS PS PS
U
U U U
External S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S. S S
PS PS PS
U U U
8) Other (Specify) S PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
.Recommendations/Comments:
Described by Title ,�. Date
SITE DIAGRAM
DCHD(6-82)