947 Peoples Creek Rd �^G
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�` . DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*dote: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date • / - ,r- .r'r ! '��
Location
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 ❑ zr L r
Auto Wash Machine YES ❑ NO i❑
Type Water Supply 011
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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 Completion � 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.
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DAVIL COUP?TY HEALTH DEPART IEI?T
EPIVIROIII-MITAL HEALTH SECTION
SOIL/SITE EVALUATIOV
VALDE 1Z0 W AL-►'D V f�£R-T-U^ DATE
ADDRESS 335^ 2R(uzc;'A-P 5Z V
"C-V-J'%JfLCt, jam/L Z?014'6 LOCATIO14 P��Qc £s L2E4 k- R-0.
LOT SIZE
TOPOGRAPHY: �oV�
40
SOIL TEZ TURF: 5A-PP-1
SOIL STRUCTURE:
DEPTH:
RESTRICTIVE HORIZOFS:
PERCOLATION FATE: Presoak Turk & time I Drop Time Rate/Ifin. Inch
2. P P-1 PIP- 3/i I� o 7 �'►+Pi 3c�in�Jfrt�cC
s. 3u fvc-� co Ise I yz ► )' lti 1 r o
***CLASSIFICATIOIT:Suitable Provisionally Suitable Unsuitable
COMMIITS:
SANITARIAr
SITE DIAGRAM
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DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSEIJT FORM
INSTRUCTIONS/PREREOUISTES
1. Complete the farm below and return it to the Davie Co. Health Department.
2. Along with the form, remit the amount due as shown on enclosed statement.
3. Carefully follow 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.
DETACH HERE AND RETURN. TO THE(DAVIE COUNTY HEALTH DEPARTMENT,P.O. BOX
(MOCKSVILLE, N.C. 27028)
i
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
LOCATION OF PROPERTY: Txy n[ o.J. pece/t s er-fd DATE RECEIVED
„ ��, ��( -(K,� (office use only)
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�frL�s�S. tttT�r �tiinl i wq •w �r:�c w,�� 5�'=� i•. l�a� W
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yes `bio* (l._) I am the owner of the above described property.
yes no (2.) I am not the owner of the above describ d property, howevLr, I
certify that I have consent from jl ,owner to
R/CJ owner's iLfAnie
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 aground 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:
Owner Only
�j Owner's designated representative
' Anyone requesting results]
DATE Only those listed below _
SIGNATURE �
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DAVIE COUNTY HEALTH DEPARTMENT
ENVIR01114EIlTAL HEALTH SECTION n
P.O. BOX 57 lY, -7
MOCKSVILLE, N.C. 27028
(704) 634-5985
STATEMENT FOR SEPTIC TANK IMPROVEMENTS PERMITS AND/OR SITE EVAAjLUATIONS
NAME �0AAL'a1Z6t'3�(L7S�- DATE
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ADDRESS �' R i.�la'ri�17 S fl• PERMIT NO. 2�
EXPLANATION OF CHARGE SITSVA+-v�'17H•- / �N^P�u�9'►�'�'�C'�
Ai`MUNT SANITARIAN �! rAr-
PLEASE REMIT THE ABOVE AMOUNT OF RECEIPT OF THIS STATEMENT.
*NOTICE: Evaluation(s) can not be.complated until payment is received.
Improvements Permit(s) can not be issued until payment is received.