1010 Hwy 801NDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'a,NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name /` ;��/ % "i,: j" �' /'',r; Date "' . 1
' i.
Location
Subdivision Name Lot No. - Sec. or Block No
Lot Size
House
Mobile Home — Business __ Speculation
No. Bedrooms
No. Baths
! X.
No. in Family _
Garbage Disposal
YES ❑ NO
Specifications for System:
A
Auto Dish Washer
YES NO
Auto Wash Machine
YES NO
❑
�-� .y ` �, } /f .
Type Water Supply
/r
__—
'This permit Void if sewage system described
belowas-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.
i
Final Installation Diagram: System Installed by,_%��-r
Certificate of Completion-��'->(f� - 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 �Jp�
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By e • L Qh �' e Rf t_d
2. Address It 7�". / l n l)V EZ(a o6d Vo n e, A/C,
3. Property Owner if Different than Above
Address
Home PAO g9eY - 5 kf e AV
Business Phone 91 !% —21P 7 - 2 C0 /
Qi (9O in
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 Mobile Home V Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions W X
Bed Rooms Bath Rooms t X12- 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 A)O sinks
8. a) Type water supply: Public V" Private Community
b) Has the water supply system been approved? Yes No x h a Ue
A o f oplo l p. c
9. a) Property Dimensions 190. 21 X a54. (0
r
b) Land area designated to building site (2CYe
c) Sewage Disposal Contractor Ri clh rd mobt-,
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.
2I29 %R8
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
. 1*
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
LO ATIQN OF PROP DATE RECEIVED
ON �e Jf s,de��-f'f�ai 8o/" Jot"fhc �u�f (office use only)
SI -OV.- A-4 eX�rl:ny 4"S"I
yes 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 , 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.
DCHD (11 /84)
2-2�9-
DATE
.o.
SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
wner only
Owners designated representative
Anyone requesting results
— Only those listed below
2zglSI
DATE
SIGNATURE
Name
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
'K kloldllr-
Date
Lot Size Z��
FACTORS ARFA 1 ARFA 9 ARFA 3 epee n
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
(PSJ
PS
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
I) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
�
Available Space
S
S
S
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6.82)
S—SUITABLE PS—Provisionally Suitable
Title % Date