153 Underpass Rd a4
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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*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 , �rll <' ��� �/�' a.�! �� Date �/ i)�J U
T` _
Location
SubdivisioK Name Lot No. Seca or Block No.
Lot Size/( House Mobile Home _ Business Speculation
1
No. Bedrooms No. Baths No. in Family 7
Garbage Disposal YES .i] NO 2- Specifications for System:
Auto Dish Washer YES NO fl /aG^�/ jl-7' 19 z�U �x
Auto Wash Machine YES NO p V ^ /
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
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Certificate of Com letion X�
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.
4 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT '
Davie County Health Department �.�
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone '1(0$"9wo
1. Permit Requested By -� +��'�� � p��o\� Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-!L Alter Repair
b) Privy ✓ Conventional Other Type
Ground Absorption
Sub-Division Sec. Lot No.
5. System used to serve what type facility: House '" Mobile Home Business
Industry Other
b) Number of people 4
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions to�9 \35 y{• �oor�S
Bed Rooms Bath Rooms �a Den w/Closet
Xif
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 y urinals n garbage disposal Q
lavatory showers washing machine
dishwasher sinks a
8. a) Type water supply: Public Private to**' Community
b) Has the water supply system been approved? Yes No V J7o A,,--
9.
9. a) Property Dimensions SOo'k "Ak'g/ X "�3Q� ?" &'"&6'
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? Kcil —
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Ovker Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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Q1 PT* i o
p e,J
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DCHD(6-82)
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
�`��y 'vsv��. \0�.,��•"4�e�-�a�. (office use only)
yes no 1. I am the owner of the above described property.
yesno 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 Departmentto enter upon the above described propertyand 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
,,Anyone requesting results
�
/ Only those listed below
DATE SIG TURE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��� Date ��
Address Lot Size
FACTORS AREA 1 AREA-2 AREA 3 AREA 4
�1) Topography/Landscape Position V cv
`''PS PS PS FPS
U U U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay) ( N U PS
3) Soil Structure (12-36 in.) Ste, S
Clayey Soils
4) Soil Depth (inches)
U
5) Soil Drainage: Internal
U U U
External S –��
U U U
6) Restrictive Horizons
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 - S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �� Title Date l
SITE DIAGRAM
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DCHD(6-82)