198 Rock House Rd (2) ` _ - — _. - --•r-.v.....ar,��s=.�--a�ar� 'r.,�.' - :w. - - .�{L.'le4" (Lj /q''1,, :.
DAVIE COUNTY HEALTH DEPARTMENT
` _IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ,pryer
*NOTE;` Issued'.inlCompliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name . , tii r\j Date 4681
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Locations
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Subdivision Name 'Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home _ 1/. Business _— Speculation
No. Bedrooms A No. Baths _ No. in Family -
Garbage Disposal. ' YES ❑ ,NO [2, Specifications for. System:
Auto Dish Washer YES!. ❑ 'NO, �/ f C3 Y�� rets a - 5� - NZ...o'.
Auto Wash Machine YES.'fI . NO
Type Water Supply �:► �; � ---
*,This permit Void if sewage system described"below is not installed within.36 months from date of issue.
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: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
14✓. .
— � — 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 PERN11t 3657
Davie County Health Department �0%. 11 y�
Environmental Health Section
P. ���MG
O. Box 665 011
Mocksville, N.C. 27028 Its
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 99�569
1. Permit Requested By cd shre Business Phone
2. Address 3 a s✓, C D
3. Property O ner if Di erent than Above r" 36�.%2
Address -f- 7/a' �• / �i,. 1' i`/�yl �,�C '
4. Permit To: a) Install �Alter Repair n�6
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile HomeV"Busines
s
Industry Other
b) Number of people 12-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms a?— 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 Community
b) Has the water supply system been approved? Yes No ✓
9. a) Property Dimensions ate. 4:�7� `1�
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? `��' z ✓�
This is to certify that the information is correct to the b t of my knowledge.
ate Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND OCAL LAWS
Allow 5 days for processing
(rections to roperty•0.0
.eco eco
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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: IDC-,- 2, DATE RECEIVED
(office use only)
yes no 1. 1 am the owner of the above described property.
yes ( 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 conductall
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
— Owners designated representative
Z'701
nyone requesting results
Only those listed below
'10 a4't1-
DATE SIGNATURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT 46
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
c SOIL/SITE EVALUATION
Name C-)� �� J� R v' C� y R.�t Date -
Address Lot Size
FACTORS ARA 1 ARC;�) AR 3 AREA
1) Topography/Landscape Position SSSS
P P
U U U
2) Soil Texture (12-36 in.) Sandy, S S -
Loamy, Clayey, (note 2:1 Clay) ® q � � PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils (i!5 U *P 1p�'
. , U U
4) Soil Depth (inches) r S _.S
P 6 (US P. PS
U U U
5) Soil Drainage: Internal � � <�
FIn U U U
External
P PS P
U U
6) Restrictive Horizons
7) Available Space
PS PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by -` Title cam? Date
SITE DIAGRAM —�
od
0
DCHD(6-82)