230 Pine Forest Ln DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:`Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name -� ���is� �, '�/ �/� Z01 / Date .—Z–/ti
Location
ZI
Subdivision Name Lot No. Sec. or Block No.
Lot Size House �` Mobile Home _ Business _— Speculation
No. Bedrooms `1,r No. Baths — No. in Family _
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES NO ❑ �Oo`
Auto Wash Ma.hine 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.
. � 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 4 T (7'zZ4
U
1
1
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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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
j
Environmental Health Section
� lqr P. O. Box 665 .010 VL
� ) Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEZISSUED.
7/Y/lltlltr�M, Home Phone-412--73,q 9
1. Permit Requested By �O U.5e A�,/ ��� usiness Phone�92 -7Z V
2. Address ! Oax 279 ' sf'�l MncksuAe /U.e_,27025?
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓Alter Repair j�q b) Privy Conventional Other Type Ground Absorption ��'c) Sub-Division Sec/ Lot No.5. System used to serve what type facility: House ✓ Mobile Home usinessIndustry Other—
b) Number of people 5
6. a) If house or mobile home, state size of home and number
of rooms.
House Dimensions X �� / •7� -
Bed Rooms L _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 7 urinals 2 garbage disposal
lavatory 52— showers 2 washing machine /
dishwasher / sinks f
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No-Z
9. a) Property Dimensions 2-TO k 30 b �
b) Land area designated to building site Chn-UL n metn bonk 105 p A r E 3aj
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? hL0
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82)
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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
�flY)GGowirt a ��� b�YS ieo,�d. (office use only)
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 , 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 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.
DATE S G,NATURE
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
1194
DATE SIGNATURE
DCHD(11/84)
' DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Box 665 ,
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date �1 .
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position �S S S S
6!W 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
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 S
8l 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
r
U—UNSUITABLE S-SUITABLE AS—Provisionaliv Suitable
Recommendations/Comments: e
Described by Title Date ���
SITE DIAGRAM
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DCMD(6-82)