503 Georgia Rd„:. r.n....<,., s. :r;.,a. .r•i «;it -.. -. �. .. , '. ... ., .. ... _.•..
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DAVIE COUNTY HEALTH DEPARTMENT
b�K `
Subdivision Name
"
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Lot Size <�
*NOTE:
Is ue. in Cor-opliance with .S. of North Carolina Chapter 130 Article 13c
Business Speculation
No. Bedrooms r'-
No. Baths r}
e�rlage reatm�nt and' bispos�I Rules (10 NCAC 10A .1934-.1968)
Permit
Number
Name
Date
Specifications
Location
Auto Dish Washer
YES NO ❑
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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�
r
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.
b�K `
Subdivision Name
"
Sec. or Block No.
Lot Size <�
House
Mobile Home
Business Speculation
No. Bedrooms r'-
No. Baths r}
No. in Family
I
Garbage Disposal
YES ❑ NO
Specifications
for System:
Auto Dish Washer
YES NO ❑
Auto Wash Machine
YES NO -❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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�
r
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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section RECEIVED DEC 6 7
P. 0. Box 665'
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/ L C,o'�'L�"✓� �-/ Home Phone �`- 0�27,F3a
1. Permit Request d By A/774 1'q A� Business Phone
2. Addresse3 % � ? Eq=f /V C a ? o .z
3. Property Owner if Different than Above
Address "'// - / / %o ��
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absor tion
c) Sub -Division Sec. Lot N
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions / 6` 'r G
Bed Rooms 57 Bath Rooms '2 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 a urinals garbage disposal
lavatory showers / washing machine /
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /0 .g- c X,97S X -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? n U
This is to certify that the information is correct to the best of my knowledge.
Date 7Ow r Signatu
IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing \\
jbirectioA�'to property:
'!�0/ '�V' -
34-D ?Z -e- e,7'
DCHD (6-82)
717
r or 0 S if o A"-<- s / Pte` .
Js 'L_i ,(__
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, R O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
Old
_ !'��0 �.I I/j//�� (office use only)
Al
yes no 1. 1 am the owner of the above described property.
ye no 2. 1 am not the owner of the above described property, however, I certify that I
.
have consent from =c , 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 property and conduct all
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
/,) - 7–t7
DATE
SIGNATURW'
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
/d- 7–f7
DATE
DCHD (11 /84)
SIGNATURE
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168.3
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Namek ��b,j,,� n� Date 1Z –11 1 �j
Address A" T"' -p Lot Size �1 H
FACT(1RR ARF1A 1 \ ARENA 2\ AREA 3 ARFA 4
1) Topography/ Landscape Position
S
p
S
S
PS
S
PS
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
P
S
PS
S
PS
U
U
I) Soil Depth (inches)
S
PS
S
PS
p
U
U
U
i) Soil Drainage: Internal
APlu,
S
S
PS
S
PS
U
U
External
S
p -
S
S
PS
U
S
PS
U
i) Restrictive Horizons
Available Space@
PS
QS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
1) Site Classification
U—UN, SUS BLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:–
Described by - Title _ Date
SITE DIAGRAM
I
UCHO (6.82)
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