926 Rainbow Rd DAVIE COUNTY HEALTH DEPARTMENT p�)
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 6EkC'k � C"A� _ Date � '.c, '
Location \`_, Y t
Subdivision Name` Lot No. Sec. or Block No.
Lot Size _ House ! Mobile Home — Business Speculation
No. Bedrooms -- No. Baths — Z No. in Family
Garbage Disposal YES ❑ NO E] Specifications for Systeme
Auto Dish Washer YES ,Q N0�❑ Q- —�
Auto Wash Machine YES E3 NO ❑
Type Water Supply C., 0
*This permit Void if sewage system dpscr*beg below is not installed within 36 months from date of issue.
I ,
I
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 —t���L' \•r� �'�-
r _
11 a-
g�
\ f
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 O
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 0n'8"-lLIq(p
1. Permit Re nested By 11\O'na
�� Gene \4pyx-_1\ Business Phone
2. Address �- —Tt a
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 Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business
IndustryOther
b) Number of people LA
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions G00 �0
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 Z` urinals garbage disposal
lavatory showers washing machine
dishwasher i sinks -�
8. a) Type water supply: Public Private Community_ZCD_q_r%4,-j
b) Has the water supply s oved? Yes No
9. a) Property Dimension y N
b) Land area designated to buil )ng s( e
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? t
What type?
This is to certify that the information is correct to the best of my knowledge.
3 1 1 1 q & dw_��
.0
Date 1 Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing I
Directions to property: \m , IS g -�o To'k n bovv R Cckd . TU rr-\ e-� Cr,I o 'Rain bow) d
Go rox irnc��-el ly Imp 6z, -�u rn H�lr4 On f�a-(r)bo W Go 'IL4
DC7-1C� '
O
0
IS 8
DCHD(6-82)
=� 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
(office use only)
i ' n ha w 'Road
(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.
91311
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
Owners designated representative
Anyone requesting results
Only those listed below
3 3 187
DATE SIGNATURE
DCHD(11/84)
. DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
1 1 I SOIL/SITE EVALUATION C�
Name , ��` ryc� W QDate
Address S tom,p Lot Sizer
FACTORS ARE 1 1 AREC2 ARE 3 AREA 4
1) Topography/Landscape Position S
ch) PS
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PSP P PS
3) Soil Structure (12-36 in.) S S S
Clayey Soils S P PS
euesDUU
4) Soil Depth (inches) S S
PSOP PS
U U U
5) Soil Drainage: Internal S M S
PS PSS P PS
yJ j U U
External S S
PS PS P PS
to: U
6) Restrictive Horizons
7--
7) Available Space S S
>� PS
b� U
8) Other (Specify) S S S S
PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE QPSovisionally Suitable
Recommendations/Comments:
Described by Title Date a SITE DIAGRAM
DCHD(6-82)