The URL can be used to link to this page

368 Potts Rd (2) DAVIE COUNTY HEALTH DEPARTMENT i IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION l r8 ( , *NOTE: Issued in Compliance with G.S.-of North Carolina Chapter-130:.Article 13c Sewage Treatment and Disposal Rules (10 NCAC 10A .193 -.1968) Permit Number l�ad µ Name Q� Date N_ ,�„ i';, f Location �'C U �, C-'� y �,�,c.Q i 11 e , r1 bo , Subdivision Name Lot No. - Sec. or Block No. Lot Size I S X D,5`0 House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family Garbage Disposal YES ❑ NO 12/ Specifications for System: Auto Dish Washer-. YES,gy NO p Auto Wash Machine YES ©' NO'C] Type Water Supply �.�_� r�� - ' � �J Q, � J► X }°'-��►� - *This permit Void if sewage system described below is not installed within 36 months from date of issue. Lt— F Improvement permit b _`� � 3 ' 1 � p P Y *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 r v � 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 nawD JUN 1 5 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Req ested By —Business Phone 2. Address oq 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Re b) Privy Conventionalpair Other Type Ground Absorption c) Sub-Division Sec. Lot 5. System used to serve what type facility: House Mobile Homed Business Industry Other b) Number of people 6. a7 If house or mobile home, state size of home and number of rooms. / House Dimensions IV X d Bed Rooms_Bath RoomsDen 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._- Idd SAG� 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 Co munity b) Has the water supply system been approved? Yes No 9. a) Property Dimensions b) Land area designated to building site 1114r� X c) Sewage Disposal Contractor & 722 S� 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is correct to the best of my knowledge. U -l — Y '9 r T Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: z - yo ��sT Te� ra P,4 7- ir e Z e /47T i l e P(6� Z � e DCHD(6-82) 1.. 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 1 (office use only) j of 3 177ve, wlewroe Parr iP6 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 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 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 wners designated representative Anyone requesting results Only those listed below -/z, (l DATE SIGNA RE DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE \\EVALUATION p NameiS`/ e.� Q.P a N Date Vy Address tri Lot Size 0 FACTORS AREA 1\ ! A A 2 AR Ad 4 6 �J 1) Topography/Landscape Position U U U U 2) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) U U 3) Soil Structure (12-36 in.) Clayey Soils ^ P U U U 4) Soil Depth (inches) c U U 5) Soil Drainage: Internal --S� PS PS (*P PSS SDS 1 External S - PS PS's 6) Restrictive Horizons 7) Available Space S S S U 8) Other(Specify) S S S S PS PS PS S — U 9) Site Classification U—UNSUITABLE S--SUITABLE PS—Provisio liy Suitable Recommendations/Comments: Described by `- ' - TitleDate SITE DIAGRAM 04 i Ly DCHD(8.82)