P3456 Gladstone Rdr DAVIE COUNTY HEALTH DEPARTMENT
' I IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION L
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewa e Treatment and �Vis;sal,
'Rules (10 NCAC 10A .193✓4-�.1968.i) +7 Permit
ermit Numbe
r
Name Date456
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home— Business Speculation
No. Bedrooms . No. Baths) No. in Family
Garbage Disposal YES F1 NO E:]e
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO
Type Water Supply J' ---
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit b
*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:
Certificate of ComP le ion/C` �l,t 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.
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Name_
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Date �� C
Lot Size
AREA 3 AREA 4
AREA 1 AREA 2
Topography/ Landscape Position
S
PS
S
�
S
PS
S
PS
U
U
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
j
S
PS
S
PS
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
��p�
S
S
PS
U
S
PS
U
U
i) Soil Depth (inches)
S
S
S
S
�PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
PS
S
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
I) Site Classification
U—UNSU
Recommendations/ Comments:
BLE PS—Provisionally Suitable
Described by Title - Dat C-
SITE DIAGRAM
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DCHD (6-82)
APPLICATI N FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
/ R 0. Box 665
f �S' Mocksville, N.C. 27028 ��p
CONS/TRUCTI%N HAL rJt�}TT-.1MPROVEMENTS PERMIT HAS BEEN ISSUED.
WJAM . ll
Georgie S. Wilhelat Home Phonq 19) 7V-13907m;o�t�}
2311 Mullins Drive
1. Permit Requested By� g _ p � j p� Business Phone (A l!b 7ag.-a4 g A-)
2. Address Win%A`"
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
` b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used -to serve what type facility: House–V_ Mobile Home -Business
IndustryOther
b) Number of people -rr 3
6. a). If house or mobile .home, state size of home and number of rooms.
House':Dimens• s 214 X -4!9
'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 ' 2- urinals garbage disposal
a atKrr 2 showers z�— washing machine
dishwasher sinks Q�ub�e� 1�i�Gi�tt1
8. a) Type water supply: Public Private Community
b) Has the water supply system been iapproved? Yes ✓ No
9. a) Property Dimensions- __ GYCCE S
;.,b)'Land area'designated to building site
c) Sewage!Disposal Contractor rr .
10 . Do you anficipate any additions or expansions of the facility this sewage system is intended to serve? Irl
What type?
0
This is to certify that the information is correct to the best of my knowledge.
hESPOt�fSIBLE FOR COMPLIA E WLl `I�TI
Allow 5 days for processing
Directions to property:
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DCHD (6-82) - ( t �.1�.�V.G 1 + l J • - �� -��'`(�
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DAVIE COUNTY HEALTH DEPARTIMENT
SITE EVALUATION CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2. Along with the form, 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 COUNTY HEALTH DEPARTMENT,P.O. BOX 57)
(MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FOP11
LOCATION OF PROPERTY:
(oo► 5. +0 Glajstvnre >?oad ri5h�'
Sravfe1 roacj �lo ��5hr CaAt Y\e,W Gravel YZc�
Rgpn,x 1.4 m I'e +v P roper ,1
y -e lto W (Op e, Q rD 5 e-5 r►fr'r`2x Y'Ge
�cbm �-hete, t10 cul Toto r)\e.w c(ri ue.. -b encP -
VOLA „aivl ste a MI(I wVIV-ep- w1e, ho
DATE RECEIVED
(offiee use only)
y'eessy no (1.) I am the owner of the above described property.
I
yes no (2.) I am not the owner of the above described property, however, I
i certify that I have consent from ,owner to
i owner's name
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
1__ L property and conduct all testing procedures necessary to
determine its suitability for a ground absorption sewage
disposal system.
DATE SIGNATURES� �^^��
a�� Wl
(4.) I hereby authorize the Davie CountyH lth Department to release
site evaluation results from the above described property to the
following:
Owner Only
a� Owner's designated representative
` Anyone requesting results
DATE J—� E2 Only those listed below
SIGNATURE