120 Brookdale Drive Lot 10 Section 29/6� ,9OS-7o73
oil It DAVIE COUNTY ENVIRONMENTAL HEALTH SECTION
APPLICATION FOR IMPROVEMENT PERMIT (REPAIR)
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NAME �WAltq A110V PHONE NUMBER �30 Wk5&70
ADDRESS %w woka���� 4. Wilowee- SUBDIVISI AME
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DIRECTIONS TO SITE w j 15kl� &4 11tvy �D� P �%li ,�S et-i�' ONf�
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DATE SYSTEM INSTALLED NAME SYSTEM INSTALLED UNDER
TYPE FACILITY 11Q& NUMBER BEDROOMS NUMBER PEOPLE SERVED
TYPE WATER SUPPLY C'ouhlN SPECIFY PROBLEM OCCURRING G✓�'%! 0� ��%��Ne/
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DATE REQUESTED r 2 /� a INFORMATION TAKEN BY
This is to certify that the information provided is correct to the best of my knowledge, and that I understand 1 am responsible for all charges incurred from this application.
SIGNATURE OF OWNER OR AUTHORIZED AGENT,
Rev. ,/93
49,
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT.
Davie County Health Department
Environmental Health Section
lY P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone _1_04c�/
1. Permit Requested By • 1 i4!eniE 154ae-` S Business Phone
2. Address & APi57-F24mQ D(iKA'f /N5ryt4 ejV. - 27/03
3. Property Owner if Different than Above C r Ilio w C
Address
4. Permit To: a) Install meter Repair
b) Privy Conventional !�Other Type
—
Ground Absorption
c) Sub -Division 4 reetalV v � S�Mobile
Lot No. 16)
5. System used to serve what type facility: Houseome Business
Industry Other
b) Number of people r6.) S,Y
6. a) If house 9F meb4e4aam, state size of home and number of rooms.
House Dimensions 2 8 X 14 0 ZZgv 5Q FT 5 l DRY ?' Z3o4s& . P4 f
I i�/d �RF�n i Or ��umB�Nc� lN%4SPiIlE3�
Bed Rooms Bath Rooms Z Den w/Closet_
b) If Business, Industry or Other, State: Number of persons served A/oA(E
What type business, etc. /fid g&
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes 3 urinals garbage disposal _
lavatory 3 showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yeses No - Ooaly v Wff7e4Q Lc FT Srvt
9. a) Property Dimensions o - 2 27. D3 e 2 f s �e tz`�sT 2 i G,asT 3D6�D
I r
b) Land area designated to building site _�£L
c) Sewage Disposal Contractor �'n x� I� [ G J (� ��a w1c' �r
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? l/0
What type?
This is to certify that the information is correct to the best of my knowledge.
lyalm_'A z �44(te V&76)
Date dwner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTIMERT
SITE EVALUATIO14 CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2. Along with the farm, 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 COUMY HEALTH DEPARTDMNT,P.O. BOX 57)
MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORK
LOCATIUN OF PROPERTY:
on Pz-�rook c,dt.'6r, !-.1 10/ Seci10K Z_j
dIock q' ,
DATE RECEIVED
(offiee use only)
yes not (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described property, however, I
certify that I have consent from ,
owner's name owner to
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.
7 9�
DATE
SIGNATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to -the
following:
TURE
1W Owner Only
C3 Owner's designated representative
0 Anyone requesting results
[i Only those listed below