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689 Cornatzer Rd DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *Note: Issued n Compliance with G.S. of North Carolina Chapter 130—Article 13c. Permit Number Name �.i r� �2� r= Date c� 7 f. Location nA 7 flrl/ - i�r�•rL kU �tt n It ���+rTnu`� Wa Er� � nc, r.� Subdivision NaI a Lot No. Sec. or Block No. Lot Size r } House Mobile Home _✓ Business Speculation `3 No. Bedrooms No. Baths 1 No. in Family Garbage Dispo al YES ❑ NO [2- Specifications for System:quoc�,7) Auto Dish Washer YES ❑ NO j�o ���. �� P Ct�a. - Auto Wash Machine YES p' NO X t�L Type Water SL pply ('sa,. �l �a,,•-� -_ __ t�� (Z'r� n., ._ IC� 1— Z� r t}�14' -� Pf ra.-� �n<: . *This permit Vc id if sewage system described below.is not installed within 36 months from date of issue. e f+ a Iwo Improvements permit by v *Contact a repr sentative 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 Installatio Diagram: System Installed by ��e C s rw3 �.1 12.x` w1Yk- NC 1 Cfi QL -S.T, Certificate of Completion �� �11 '� Date *The signing of his certificate shall indicate that the system described above has been installed in compliance with the standards s t forth in the above regulation, but shall.in NO way be taken as a guarantee that the system will function satisfactorily foe, any given period of time. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address � 3 3q7- Lot Size ln,OLKSvff- Nc 2Zo24' FACTORS AREA 1 ARE&2 AREA 3 AREA 4 1) Topography/Lanc scape Position S PS S U U 2) Soil Texture (12-126 in.) Sandy, S S S S Loamy, Clayey, (rote 2:1 Clay) PS PS PS PS U U U U 3) Soil Structure (12 36 in.) S S S S Clayey Soils PS PS PS PS U U -U U 4) Soil Depth (inche ) S S S S PS �i PS c� US s�j� US 5) Soil Drainage: Int rnal S S S S PS PS ® �S7 U U U U External S Sd PS PS S PS U U U U 6) Restrictive Horizons ,lir 7) Available Space S S. -S. PS PS (]Eg� -,,- U U U U U 8) Other (Specify) -- S S S S PS PS PS PS U U U U 9) Site Classification U—UNSUITABLE _ S—SUITABLE PS—Provisionally Suitable Recommendation / omments: 6Q /9 70Z Described by Title SAr-J M(?-i AN Date SITE DIAGRAM 2 , � �" � X3 ��jz 9 3-S-'22 ) 1ZAP°� , 1- 3 2l qpaj f U' DCHD(6-82) APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT V Davie County Health Department �1 ` Environmental Health Section r)i P. 0. Box 665 �S Mocksville, N.C. 27028 ONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone `i 1. Permit Req ested B Business Phone � 2. Address II a 3. Property ©wner if Diff rent than Above Address Z O ti U 4. Permit To: a) Install X 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 n IndustryOther b) Number of people �- 6. a) If hous$ or mobile home, state size of home and number of rooms. Houde Dimensions Bed dooms 2- Bath Rooms Den w/Closet b) If Busyness, Industry or Other, State: Number of persons served In On C_ Wha I type business, etc. Estirr ate amount of waste daily (24 hours) 7. Number aid type of water-using fixtures: commodes urinals garbage disposal lavatory , , showers washing machine 1 dishwasher sinks 8. a) Type water supply: Public—Private Community b) Has thy water supply system been approved? YesX-No 9. a) PropeDimensions ("���--�� b) Land a ea designated to buildin site c) Sewage Disposal Contractor 10. Do you ai iticipate any additions or expansions of the facility this sewage system is intended to serve? What typ ? f° This is to certify that the information is correct to the be t of my knowledge. 19 y Date Owner gnature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: us �- �erdsS 0 k'kVCAN mar L, reg, 1,�e��- v��orr,�,�-�.et- 1P,oac� G� roK � mai� y a ►�� l�e�S Tlurh ��r 0g� r-o,r... C,1�t✓S-4�w'� ���t Oh COv R,�t_cv p`0 Q( -�h � rock& CX et c�t r DCHD(6-82) DAVIE COUNTY HEALTH DEPART2IENT SITE EVALUATION CONSENT FORM INSTRUCTIONS/PREREQUISTES 1. Complete the form below and return it to the Davie Co. Health Department. 2. Along with eche form, remit the amount due as shown on enclosed statement. 3. Carefully fellow the procedures as outlined in the enclosed "Information Bulletin". 4. Notify Health Department upon completion of item number 3.• NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DET CH HERE AND RETURN TO THE(DAVIE.COUNTY HEALTH DEPARTDIENT,P.O. BOX 57) (MOCKSVILLE, N.C. 27028) DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM _LOC�TION OF PROPERTY:_ DATE RECEIVED (office use dnly) CDY`iR0.�-Z�t- '�oa�9� �i��roX i mai-►y 2 Wil S 0 Le- e#f of toy eq,stae-ros s-•Oro yes no (1.) (1.) I am the owner of the above described property. yesi no (2.) I am not the owner of the above dj;qcribed_,pxoperty, however, I certify that I have consent from ,owner to owner's na e . obtain a site evaluation by the Health Department for the purpose of determining the suitability for a ground absorption sewage disposal system. yes no (3.) I 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 necessary to determine its suitability for a ground absorption sewage disposal system. DATE SIGNATURE (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: 0 Owner Only 2 Owner's designated representative Anyone requesting results DAT Q Only those listed below SIGNATURE ^ ,;;