P3792 Hwy 601SL
DAVIE 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 Dispo al Rules (10 NCAC 10A .1934-.1968) �/ Permit Number
NameDate 3!
w
Location
y '
Subdivision Name Lot No. Sec. or Block No.
Lot Size ��'t' House ��''�~ Mobile Home _ Business Speculation
No. Bedrooms - No. Baths .Z No. in Family
Garbage Disposal YES ❑ NO 21-/ Specifications for System:
Auto Dish Washer YESNO ❑, ' �� - �! ��/- `
Auto Wash Machine YES j NO ❑ ��" �� r /
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements
-
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 by
Certificate of Completion /�-- Date
L `
*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.
Address
FAr.Tr)RC
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION _
Date
Lot Size���
AREA 3 AREA 4
ARFA 1 AREA 2
Topography/ Landscape Position
2)
3)
4)
5)
6)
8)
9)
S
S
S
S
elr-rr
PS
PS
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
'��
PS
PS
PS
U
U
U
U
Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
Restrictive Horizons
') Available Space
S.
S
S
PS
PS
PS
PS
U
U
U
U
Other (Specify)
S
PS
S
PS
S
PS
S
PS
Ute"
U
U
U
Site Classification
1
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
Described by 9/ Title
SITE DIAGRAM
i
DCHD (6-82) ,
Dat
A � �
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
j Davie County Health Department /' z
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address
3. Property Owner if Different than Above
Address
_ Home Phone
4- �� r Business Phone` 29 – 2 S-- 34'0/
4. Permit To: a) Install_ Z Iter Repair f
b) Privy Conventional Other Type— S r 1 7a it,A,
Ground Absorption 0
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry' Other
b) Number of people Y
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions ']* x l Q
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 urinals d garbage disposal
lavatory showers f washing machine
dishwasher / sinks
8. a) Type water supply: Publics Private Community
b) Has the water supply system been approved? Yes_LGNo
9. a) Property Dimensions 4 At
b) Land area designated to building site G .p C e �,:I
c) Sewage Disposal Contractor ��'� Y i, •� T� FA k
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? AJ 1)
Whattype?
This is to certify that the information is correct to the best of m o edge.
Date Ow Signa
OWNER IS SOLELY RESPONSIBLE FOR COMPLIAN WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
G / hbyi, /� o �ksY; 1�e,,Pl ; 1 s
e—)Olr _e ty ejC a j A k4- d! - 0f
DCHD (6-82)
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. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
1), �wc�Y Gb 1 yrt'��s �rO �"�T'" Pc ��o (office use only)
of .r T C. JYyCci`Cl
es no 1. I 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 Departmentto 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.
DATE SfGNA
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
— Owner only
0 ners designated representative
/Anyone requesting results
Only those listed below
DATE
DCHD (11 /84)