373 Boxwood Church Rd'4sln.tY� ..: d,r<Soa`"'c' ''.-W-a°.i'y.e.F w�...� 'ww >.�.er.. A.t. v✓ ';:9:'u .r *'iQ-jnL*s-'v".�:
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DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOT in Compliance with G.S. of North Carolina Chapter 130 Article 13c
t. S wage -Treat ent and Disposal Rules (10 NCA 1 A .1934-:1968) Permit Number
i f� :� ,� ��/�-. ,ire. F„� / �%,� . � Lr ��i tt, �
Name P - vrCi, r � Date :.1 .� C
Location e'�Zrv. , f ' t ,✓� .� �
i
Subdivision Name Lot No. _ Sec. or Block No. I
Lot Size 4a{'- House Mobile Home _��� Business Speculation
No. Bedrooms c_ No. Baths No. in Family �.
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES N0 ❑ ,) yrs f� , , i
Auto Wash Machine YES NO ❑
i
Type Water. Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
1
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
?o
Certificate of CompletionDate Y7
"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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section RECEIVED MAR 2 0 1389
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROyEMENTS PERMIT HAS BEEN ISSUED.
yPermit Requested By
2. Address 21010. A61?Q
C3
3. Property Owner if Different than Above r 14
Address
4. Permit To: a) Install�ef'–""Alter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone
Business Phone
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home_iGBusiness
IndustryOther
b) Number of people
"�'�`I
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms .L— 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 urinals
lavatory ! showers
dishwasher
sinks
garbage disposal
washing machine 1
8. a) Type water supply: Public Private ✓ Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions �t
b) Land area designated to building site ✓
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
3 ^2 a
. Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: ,,g.,it-P9
/V7l' ^&-J, w
DC�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FAr.Tr1RC ARFA 1 AREA ? AREA 3 ARFA d
1) Topography/ Landscape Position
d
PS
6P
PS
(::9)
PS
0
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
TTTTJJJJ
( P5J
i7�
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
co
-
PS
(PS)
U
U
I) Soil Depth (inches)
P
h
S
U
U
U
i) Soil Drainage: Internal
S
S-
-
p
U
U
U
U
External
Sb
U
(!9)
U
A
U
�) Restrictive Horizons
Available Space
.
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
i) Site Classification
. �,
��U
Ls-.
l J
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by / - Title
SITE DIAGRAM
L�
UCHU (6-82)
�3
Xy
Date �!
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
SITE EVALUATION CONSENT FORM
1. Complete the form below and return to the Davie County Health Department.
2. Carefully follow the procedures as outlined in the enclosed "Information Bulletin."
NOTE: THE ABOVE MUST BE COMPLETED BEFORE A SANITARIAN WILL BE ABLE TO
BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO: Davie County Health Department, Environmental
Health Section, P. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
X�'CrJ�i /pie Cou y (office use only)
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 - l --) , 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.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described propertyand conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
— Owner only
— Owners designated representative
Anyone requesting results
Only those listed below
DATE IGNATURE
DCHD (11 /84)