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137 Shutt Rd.c.-•-` i "^.. t:,.s�i;v`wL'-V :. r i�J - C,i�' ..��'r$ �«» ..,.,.y.w,.i,.sw,.,'u ,'.!. l . .r` ., .+. .rk..,-......�, �J» .w.., .,.., .., ., ,,..o.. , Vv' .+..v.M.4.^`�: .t..w,.,, ..z.•., r w ...dam. awe� � . .: _....,. _ ,. DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION j TE:-"Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c ' - Sewage Treatment.,and�Disposal Rules (10 NCAC 1 O .1934-.1968) Permit Number r, ;i�' .r �i'r-'�: ,ly-r` ;Y�. /.r l: Date Name ?/lt'/ r. N Location ,�S 21"L �5`�, {/ Subdivision Name Lot No. Sec. or Block No. Lot SizeHouse Mobile Home rte-' Business Speculation No. Bedrooms — No. Baths — No. in Family Garbage Disposal YES p NO Specifications for System: Auto Dish Washer YES NO Ej Auto Wash Machine YES NO ,0 / Type Water Supply `This permit Void if sewage system described below is not installed within 36 months from date of issue. l� 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.4::2 ' 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. • � ' .L�+ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department O r Environmental Health Section Q,. P. O. Box 665 G� Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone Q �0 1. Permit R sted B y Business Phone l Q V— Ll -paj ,`� 2. Address - 3. Property, Owner if Different than Above , Address 7S r <Le'Jc �-�, AIC, 2-10d'42 4. Permit To: a) Install Alter Repair b) Privy Conventional Other Type Ground Absorption c) Sub-Division Sec. Lot N 5. System used to serve what type facility: House Mobile Home Business Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions Z�X Bed Rooms 3 Bath Rooms '�Z 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 Z washing machine dishwasher sinks. 2 8. a) Type water supply: Public Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 4 azd o-o b) Land area designated to buildin site C) Sewage Disposal Contractor 10. Do you anticipate/any additions or expansions of the facil( y this sewage system is intended to serve? What type? A h O /This is/to certify that the information is correct to the best of my knowledge. Date Owner Si nature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: �SW 1n7 ktio owner Slee ,✓ /� �]my�,s 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 Lw (office use only) yes no 1. I am the owner of the above described property. yes no 2. 1 am not the owner //of�f the above described property, however, I certify that I have consent froml�e�tJ �✓ , owner to obtain a owner's n me 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. G V DATE SIGNATOR 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: Owner only X Owners designated representative —Anyone requesting results Only those listed below Alf Z DATE SIGNATURE DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section ' P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name � � � Date ZC,l E�� Address Lot Size 45;:�2 FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S S S © PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) P PS PS PS U U U U 3) Soil Structure (12-36 in.) S S S Clayey SoilsPS PS PS &tuj U U U 4) Soil Depth (inches) S S S PS U PS U U U 5) Soil Drainage: Internal S S S S PS PS PS U U U External S S S SS PS PS PS U U U 6) Restrictive Horizons 7) Available Space 7 S S S PS PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS z U U U .9) Site Classification . S U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: Described by Title Date v �� SITE DIAGRAM 1 DCHD(6-82)