241 Will Boone Rd DAVIE COUNTY HEALTH DEPARTMENT
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rIMPROVEMENTS 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 //_!/,� `�S/ '`C :�" i...:,T Date
rr 'Sr• �/,�'' `�fi!/ 7✓ / ���!r'"r".t'�'%t;"1,
Location
Subdivision Name Lot No.
Sec. or Block No.
Lot Size House Mobile Home J,�__ Business Speculation
No. Bedrooms — No. Baths c No. in Family t
Garbage Disposal YES :[-] NO Specifications for System:,
Auto Dish Washer YES NO
Auto Wash Machine YES NO Ej
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
cis '
01
Certificate of Completion -A r- 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
Davie County Health Department
Environmental Health Section �r�
P. 0. Box 665 RECEIVED JUN 2 2
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
nn (( Home Phone
1. Permit Reqested By j0^QS WeSke (20s1" e- Business Phone
2. Address 140,-4,
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. - Lot N�oo
5. System used to serve what type facility: House Mobile HomeZ Business
Industry Other
b) Number of people o2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions A _� r)(:.:I
Bed Rooms a Bath Rooms cZ 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 9 showers 0- washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
munity
b).Has the water supply system been approved? Yes No
9. a) Property Dimensions �•
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? YIQ
What type?
This is to certify that the information is correct to the best of my knowledge.
t 99" gr)i - 6., Z,�U
Date Owner nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS `
Allow 5 days for processing
Directions to property:
Zo/s - T./ell ,a�0.�-� ,moo. /•,�f Lv:l� I� _ ,�� _ p.o sr �3,.,a0f� �. -f
DCHD(8.82)
y s ,
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
Wt'll� Y1� �4 (office use only)
(:;Ze;D no 1. 1 am the owner of the above described property.
yes no 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. .
�esno 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.
�a-g� arnQ2 1AJ. l�
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
�nyone requesting results
Only those listed below
-8r1 G�
DATE SIGNATURE
DCHD(11/84)
fi
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
Name
SOIL/SITE EVALUATION
Date - 4�Z��ff
�Y�C
Address Lot Sizef �
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) T S S S
Clayey Soils PS PS PS
U U U U
4) Soil Depth (inches) S S S
USP
g PS PS PS
U U U
5) Soil Drainage: Internal S S S
pg PS PS PS
U U U
External S S S
PS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
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 i
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title �/ 71� Date
SITE DIAGRAM
l�
DCHD(6-82)