798 Sheffield Rd (2) z_ DAVIE COUNTY HEALTH DEPARTMENT • �� ,� 8v'�
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Nu.lor
Name�!1s c Date --a b / ND 6 8 ;e&
R
Location _
ll _ N
I� _'l W�
Subdivision Name r Lot No. Sec. or Block No.
Lot Size��y3`` A� r House Mobile Home _Y Business _— Speculation
No. Bedrooms No. Baths ` No. in Family =
Garbage Disposal YES ❑ NO - Specifications for System: V_
Auto Dish Washer YES ❑ NO ( ] b p p
Auto Wash Machine YES (Z NO ❑ n U� i 1 �;i 5 �
. 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.
y
F
}
------------
A(Z
Y±-T
o e"
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
l�
Certificate of Completion ` L�— 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 • LA
` IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a v1P
Sanitary Sewage Systems Permit Number
Name a ` `c Date
h�
Location �j� ,.aj '�. o� .� �) , �- �. �:.� U� �. HiR�ti
t`) WR �~� k`�� i ��N •'1 CGCJ�. � � �� i%r l..ii it r.l: !�
Subdivision
Na1me V ✓ ` Lot No. Sec. or Block No.
Lot Size ► A4 '�W� House Mobile Home —1� Business Speculation
No. Bedrooms No. Baths No. in Family---.;..-",
amily .;" _
Garbage Disposal YES ❑ NO , j Specifications for System: �� (
Auto Dish Washer YES O NO
Auto Wash Machine YES ®' NO ❑ rl r
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.
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--
Certificate of Completion 9- 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
A Davie County Health Department
" Environmental Health Section O
P. 0. Box 665 R C�wrGO MA
Mockaville, NC `27028
r.
1 . Application/Permit Requested By M V,-,
Mailing Address • fox LAV) rSk00_tbV1IIt , 1J(t, a2621
Home Phone q �a �Q�`'�31y5 Business Phone _q 1O1' gqg" 7ao1`�
2. Name on Permit if Different than Above '`+
3. Property Owner if Different than Above _SaAkti, Gr._�)exn%noAe.('
4. Application/Permit For : 0 General Evaluation @/S/Tank Installation
5. System to Serve: House V_Mobile Home 0 Business
Industry u Other Unknown
6. If house, mobile home: Subdivision Sec. Lot,
No. of Peopled Dwelling Dimensions la.X lP�
No. of Bedrooms o'? Basement/Plumbing
No. of Bathrooms . l ` Basement/No Plumbing
VWashing Machine J Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
S. Type of water supply: Public 0 Private a Community
9. Property Dimensions
10. Sewage Disposal Contractor.
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes . 9/190
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of -5
years from date issued. Improvements Permits, are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the!
best of my knowledge, and I understand I am responsible for all
charges incurred from .this application.
Date Si nature
Dire__:tj,an3 to Property :
cY�e_VIS �-
Q,��e-� p0.'SS •��' ��--k�, C -r�.re.,.��y o J�� r�c��.'r b� P_�
v��d•�.
DCHD (10-89)
Ay • t
t." 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
e (office use only)
yes no 1. 1 am the owner of the above described property.
es no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from S0.. a-, 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.
es 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 SIMNATUAt
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
•
a 9-C111 !
DATE STGNATURE
y
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name C' �- Date -
Address P. "�`�� Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position g
S,�G PS S
2) Soil Texture (12-36 in.) Sandy, 51--<° S
Loamy, Clayey, (note 2:1 Clay) C p PS
U
3) Soil Structure (12-36 in.)
Clayey Soils PS P
U
4) Soil Depth (inches)
PS VP
U U U U
5) Soil Drainage: Internal
PS P &;)
U U
External DS cis' <:*
U
6) Restrictive Horizons
7) Available Space C--PS 4s) S
PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U . U
9) Site Classification S-1 S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: - s a A- \
° 1 n
Described by Title ' �\' - Date
SITE DIAGRAM
DCHD(6-82)