258 Granada DriveDAVIE COUNTY HEALTH DEPARTMENT
71
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issuld in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name1?17!� (A Date N2 / 6 9 N2 551 09
Location �� ✓-�, r%�/% -Z;�';
./_/�✓ %l, "/'.v /`T � ii': sir%�/:%i . Y %�ii/�� ��
Subdivision Name
Lot No. Sec. or Block No
..r
Lot Size House Mobile Home ��_ Business
1
No. Bedrooms No. Baths /a No. in Family I_
Garbage Disposal YES fl NO 0 -
Auto Dish Washer YES p NO ET
Auto Wash Machine YES 0� NO fl
Type Water Supply
Specifications for System:
Speculation
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
F
Improvements permit by
'Contact a representative of the Davie CountyHealth 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
Certificate of Completion , A �'/ Date
The signing of this certificate shall indicate that the system described above has been installed in compliance with
e 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. Permit F
2. Address
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section:
P O. Box 665 RECEIVED MAR 1 5
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
By
Home Phone
Business Phone MO -3
7 ,viol
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-DivisionA I Sec. Lot No
5. System used to serve what type facility: Ho se Mobile Home Business
0 Industry Other
b) Number of people 1
6. ay 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
C What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water=using'fixtures:
commodes urinals garbage disposal
lavatory shouters washing machine
dishwasher sinks
8. a) Type water supply: Public Private mmunity �.�
b) Has thew er supply system been approved? Yes C No c
9. a) Propertyinfens)ons�}��.�s'
b) Land --area designated to building site
c) Sewage Disposal Contractor rvna AJ ne.= 71 ighi
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? X110
What type?
• This is to certify that the information is correct to the best of my knowledge.
Date 40 Owner ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD )6.62)
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�'�rmty�iealth Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
0C d \rat V "M- ' (office use only)
yes 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.
es no 3. 1 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 as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
ATE SIGNATURSJ
4. 1 hereby authorize the Davie County Health Department to release site
evaluation resylts from the above described property to the following:
Owner only
Owners designated representative
— Anyone requesting results
Only those listed below
IS 7XWj
D• E SIGNATURj/
DCHD (11 /84)
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Name—
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size '
ARFA 3 ARFA d
ARFA 1 ARFA 9
1) Topography/ Landscape Position
(.
PS
®
PS
S
PS
0
PS
U
U
U
U
�) Soil Texture (12-36 in.) Sandy,S
Loamy, Clayey, (note 2:1 Clay)
S
q
,�,�
U
�,
('
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
PS
/ PSS
PS
t) Soil Depth (inches)
`-t1
S
II
�
`�tT
Tj
i) Soil Drainage: Internal
S
U
External
A2
P
U
( j
`TJ
`1T
i) Restrictive Horizons
Available Space
PS
PS
PS
PS
U
U
U
U
o) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by �G/� Title Date
Date
SITE DIAGRAM
S�
ID0er
6
DCHD (6.82)
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