131 Westview Ave Y'
DAVIE COUNTY_ HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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 N .�� j � (? Date -24 N2 J 2 12-18
Location,
-? _ �� �'c•.. V ���?���%-aJ,,.}�r,:y..,. y \\ c" \��J _�� _, '�\1J" '� ``Q \!�. f J !sf A;xtT-'a4.
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 - '�'
.., `Specifications for System:
Auto Dish Washer `YES ❑ NO 10 j'�j � - _t
Auto Wash Machine YES, Q' NO ❑ j
Type Water Supply _
*This permit Void if-sewage 'system described below is not installed within 36 months from date of issue.
s i
1 `
C _� ,•
. Improvements permit by
*Contact a representative of the Davie tCounty 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
a
v
F
Q6 �' ertificate of Completion Date
"The signing f this cer ificate shall indicate that the system described above has been installed in compliance with
the standard set forth n the above regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any gi en period of time.
4
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS. PERMIT 6 6
Davie County Health Department
P _
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone ("11Q) 998--o�S96
1. Permit Requested By 1A '1, k .4s Sr. Business Phone (4/4) 998- y77Q
2. Address 27)�s/62 DC%= S 1`, ► U.C, ss�'7o a2
3. Property Owner if Different than AboveOGo --r Sq.. -Atrr%a�)
Address `&mwN
4. Permit To: a) Install Alter Repair
b) Privy Conventional X Other Type
Ground Absorption
c) Sub-Division QSdermD Segue Lot No.
5. System used to serve what type facility: House V Mobile Home Business
Industry Other
b) Number of people s
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions o' s X 44(
Bed Rooms Bath Rooms X02 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 a urinals garbage disposal
lavatory showers washing machine
dishwasher sinks 3
8. a) Type water supply: Public V Private Community
b) Has the water supply system been approved?*Yes No
9. a) Property Dimensions /CC 4:) X 3S 41.1 X In:2 3 X 39a.g
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? `420
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
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Directions to property:
1-4-c 0401.500b U� s�Ne ��• �� G11 ��.Q �Ay ���
{b C' o'o .elt C� \:�.t�s �+�c� Ake ,r-: ��'b ���•� oN W�s�J��� c�Se.
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DCHD(6.82)
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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, R O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
CAoCn� ,N.c. �1ec.k C it(
yes 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 loaer SQ%Ibr�,ze 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.
ICJ 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.
ATE 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
C JAS
9
DATE SIGNATURE
DCHD(11/84)
• DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
-�- SOIL/SITE EVALUATION �Y
Name �� �'\� ` �� S Date J I r$ u
Address 5 Lot Size
FACTORS ARE 1 AREk-2" AREA 3 AREA 4
1) Topography/Landscape Position S S
(:p
U PS
�J U U
2) Soil Texture (12-36 in.) Sandy, ,- S S S
Loamy, Clayey, (note 2:1 Clay) ( P' P PS PS
�l U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils (t PS PS
U U U U
4) Soil Depth (inches) S S
pS P PS PS
U U
5) Soil Drainage: Internal S S. S S
PS PS
U U U
External S Sj S S
�pSJ� UPS PS
6) Restrictive Horizons
7) Available Space S: S S
pg PS PS PS
U U
8) Other (Specify) S PS PS PS
U U U
9) Site Classification 17-IN I
U—UNSUITABLE S—SUI \t PS— nally Suitable _
Recommendations/Comments: o� � �• ^ 1 �� --_
(� r
Described by `' Title Date ^1 r`b
SITE DIAGRAM
x2
DCHD(6-82)