No preview available
512 Deadmon Rd Lot 5P1. •, // DAVIE COUNTY HEALTH DEPARTMENT 3 �� IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTJ* Issued in Compliance With Article II of G.S. Chapter 130a anitary Sewage Systems i>>y�r ��' �ir�.. i/f Permit Number N Name 7407 r"✓'r��� xrr;>r Date �1� 1f� 0 Location1 Subdivision Name —Lot No. -�V Sec. or Block No. Lot Size/ir,.1 House v�' Mobile Home _T Business _— Industry No. Bedrooms No. Baths T -� No. in Family Public Assembly Other ,_Garbage Disposal YES ❑ NO E'r Specifications for System: Auto Dish Washer YES NO E] e Auto Wash Ma thine YES NO p , Type Water Supply *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocation if site plans or the intended use change. t,. 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., 1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985. Final Installation Diagram: System Installed by�'�y -- 1-{G ry 7- a J. L) f o 4 o A LUkiJ 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. 1. Application/Permit Mailing Address APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section P. O. Box 665 Mocksville, NC 27028 By 2. Name on Permit if Different than Above X 70 7 '�?' Home Phone�� 1Ro %C�I Business Phone 3. Application for: ❑ General Evaluation Cr Septic Tank Installation Permit 4. System to Serve: Zr/House ❑ Mobile Home ❑ Place of Public Assembly ❑ Business ❑ Industry ❑ Other ❑ Unknown 5. If house, mobile home: Subdivision l/ Section Lot # ❑ Basement/Plumbing No. of People No. of Bedrooms 3 No. of Bathrooms 4 Dwelling Dimensions ��Zd 6. If business, industry, place of public assembly, other: Specify type No. of People Served No. of Commodes No. of Lavatories No. of Sinks No. of Urinals No. of Water Coolers No. of Showers Water Usage Figures ❑Basement/No Plumbing al washing Machine Dishwasher ❑ Garbage Disposal 7. Type of water supply: (T_'� Public ❑ Private ❑ Community 8. Property Dimensions ,J All Sewage Disposal Contractor /�*P✓� 9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No If yes, what type? "NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to revocation, if site plans or the intended use change. Effective October 1, 1989. Directions to Property: a/ sU�t� ��o� WV �� �,'� S 7Q � kc, do f This is to certify that the information provided is correct to the best of my incurred from this application. —� DATE and SIGNATURE I am responsible for all charges CONSENT FOR SITE EVALUATION TO BED NE _ON ABOVE DESCRIBED PROPERTY MUST CHECK ONE: fl 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property. If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner: I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described property located in Davie County and owned by to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment and disposal system. DATE SIGNATURE DCHD (1/93) APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Davie County Health Department Environmental Health Section R 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested By Ll= Dn'1 a�� Business Phone S12/m E 2. Address 3. Property Owner if Different than Above Address 4. Permit To: a) Install If Alter Repair �,— b) Privy Conventional / Other Type Ground Absorption c) Sub -Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home Business ,— IndustryOther l7,,p CX AP / b) Number of people 6. aj If house or mobile home, state size of home and number of rooms. House Dimensions Bed Rooms Bath Rooms 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 I lavatory dishwasher urinal showers sinks garbage disposal washing machine f 8. a) Type water supply: Public k"__ Private Community b) Has the water supply system been approved? Yes�No 9. a) Property Dimensions 1 O XZj- o b) Land area designated to buildi site /q /t _ c) Sewage Disposal Contractor A V r (= S 4 O /"If. / 10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? All"° What type? This is to certify that the information is c rect 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 Directions to property: O� �/� �9 5 OCHO (8.82) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. R O. Box 665 f� Mocksville, N.C. 27028 L• SOIL/SITE EVALUATION Name --TDate Address Lot Size 60 k 400 FArTr1RS A11EZ2 J AREA 3 ARFA 4 Topography/ Landscape Position C4--) PS PS U U U U �) Soil Texture (12-36 in.) Sandy, Loamy, Clayey, (note 2:1 Clay) S c=Ra= S PS S PS U U U U 1) Soil Structure (12-36 in.) Clayey Soils' S ---,.5 S PS U S PS U U G) Soil Depth (inches) S S S PS U PS U Soil Drainage: Internal S S S PS S PS External PS PS S PS U S PS U �) Restrictive Horizons Available Space S PS S PS U U U U {) Other (Specify) S PSS S S PS S PS U U U 1) Site Classification U—UNSUITABLE Recomr,nendations/Comments: a3 S—SUITABLE PS—Provisionally Suitable Described by �- Title Date SITE DIAGRAM -- — v J00/ DCHD (6-82) ydd,