P4425 Hwy 601NDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-,1968)
om.
Permit Number
Name f'i',i f�� %�
,->� Date _t
j
-125
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size ��`/�_ House Mobile Home L''� Business Speculation
No. Bedrooms_ No. Baths_ No. in Family —�
Garbage Disposal YES ❑ NO p' Specifications for System;,
Auto Dish Washer YES [� NO ❑ :� f "' .2'
Auto Wash Machine YES NO -❑
Type Water Supply
*This permit ,Void if sewage system described below is not installed within 6 months from date of issue.
J
D
I
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
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Ice,
Certificate
P
Certificate of Completion - Date � I Uri
'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 y
Environmental Health Section
R O. Box 665 • �„
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested, By Business Phone -T-0,
2. Addressiv,,C'���nf=mfr ✓�7ac-.Es Yi��E /f/. C. a %,?
3. Property Owner if Different than Above
Address
4. Permit To: a) Install--fZAlter 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
b) Number of people �;2 '-3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /-2 X U
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
lavatory —
urinals
showers Z
garbage disposal
washing machine �j
dishwasher sinks d
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ,/-2s / k�
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.
Ira
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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//6 U,3 E oN HEFT
C�4NA
DCHD (6-82)
h
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
wv AEF (office use only)
yes 1. 1 am the owner of the above described property.
es 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.
no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Departmentto enter upon the above described property and conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE f � 9� � 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
DCHD (11 /84)
SIGNATURE
Name
Address _
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
AREA 1 AREA 2
Lot Size
AREA:3 AREA d
1) Topography/ Landscape PositionS
P�
U
is
PS
U
S
PS
U
'.) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
P
PS
S
PS
U
S
PS
U
1) Soil Structure (12-36 in.)
Clayey Soils
�
U
CV
S
PS
U
S
PS
U
G) Soil Depth (inches)/�
U
-
( PSJ
`fj
S
PS
U
S
PS
U
i) Soil Drainage: Internal
g
U
S
PS
U
S
PS
U
External
S
S
PS
U
S
PS
U
1) Restrictive Horizons
Available Space
S
S
PS
U
S
PS
U
1) Other (Specify)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �/� Title
SITE DIAGRAM
DCHD (6-82)
Date ZAA