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P4371 Ralph Ratledge Rd :I �< DAVIE COUNTY HEALTH DEPARTMENT L� -�-'L, y� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION `S *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 !' i, Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths No. in Family _. Garbage Disposal YES ❑ NO p 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. 1 J - i 4 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: Sys em Installed by 1l �T i•1 t'�S�- U'C' Certificate of Completion _ _�1�"'1�� 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. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name 43Av-% Date1 -&Z- Address 3, Q`F go Z Lot Size tYt�ucs�,1(c r,nrol-J 11� r A)- c. 2'7 o ZP FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position () GD S PS PS PS PS U U � a' U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) 41!9) � �� CP U U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils (ip < PS PS U U 4) Soil Depth (inches) ��S S S S 40 UU ` 5) Soil Drainage: Internal S T� S (V 4!99> PS U U U External S PS PS CE2> PS U U U' U 6) Restrictive Horizons " $ { SxP�L• Q7..) VI` Ro '��,��I�. �� 4AP 7) Available Space PS 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 p S U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: S%zk,,- w l� �.w< °� ,S', rn �- - 2 -I G►a- �"`�` Described by I V tea . Title - Date 8-4 2 SITE DIAGRAM r �o *3 : a a D/ r ►S DCHD(6-82) t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ej 1.1 Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested By �flv�Z� $ hA Business Phone 2. Address 3. Property Owner if Different than Above r� '�latl�wt lcQi.. Address &0(,te v,..e f_ 4. Permit To: a) Install `f-Alter Repair b) Privy Conventional ✓ 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 Z 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 36 jCS'(s'- Bed Rooms Bath Rooms 2- 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 2-- urinals garbage disposal lavatory 2-- showers Z washing machine dishwasher sinks 8. a) Type water supply: Public Private__t Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 2-'s .4c &'S 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? What type? This is to certify that the information is c ct to the st knowledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: 1170(d leP DCHD(6-82) Y. DAVIE COUNTY HEALTH Dr.PART."IEUT SITE EVALUATION CONSENT FORM INSTRUCTIONS/PREREQUISTES 1. Complete the form below and return it to the Davie Co. Health Department. 2. Along with the farm, remit the amount due as shown on enclosed statement. 3. Carefully follow the procedures as outlined in the enclosed "Information Bulletin". NOTE: ALL THE ABOVE 14UST BE DONE BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURtd TO THE(DAVIE COUNTY HEALTH DEPARTMENT,P.0. BOX-" (14OCKSVILLE, N.C. 27028) DAVIE COUNTY HEALTH DEPARTYXNT SITE EVALUATION CONSENT FOR13 LOCATION OF PROPERTY: DATE RECEIVED (office use only) yes not (1.) I am the owner of the above described property. Q I _'-, yes no (2.) I am not the owner of the above described propert , however, I j certify that I have consent fromCVa.A-.A- 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. cy DATE SIGNATbRff (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: 0 Owner Only C ' Ej Owner's designated representative ( '� 0 Anyone requesting results DATE Only those listed below d SIGNATURE