P3486 Hwy 801NDAVIE COUNTY HEALTH DEPARTMENT
I
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewa a Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name f , ' r �' /yG=� it '..�'� r 5� Date �-_ T� /� r�.�'` FNt 3486
Location - �. ... _ /r' 0 ./ Z
Subdivision Name Lot No. Sec. or Block No.
Lot Size �'%''_ House Mobile Home Business Speculation
No. Bedrooms' _ No. Baths _Z_ No. in Family
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO pr
YES NO ❑
YES NO C❑
Specifications for System: ,.
�crL:7r
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
_e.
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:
M
System Installed by
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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Named ��Tua�s -- Date
Address "'L f. ?moo, A Lot Size
FAr.TnRc AREA 1 ARFA 2 AREA 3 AREA 4
d
Topography/ Landscape Position
S
S
S
S
PS
U
PS
U
!) Soil Texture (12-36 in.) Sandy,
S
SS
CES,
PS
S
PS
Loamy, Clayey, (note 2:1 Clay)
1 7
U
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
-0
S
q
S
PS
S
PS
U
U
U
Soil Depth (inches)
S
S
S
S
PS
PS
0PS
U
U
) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
S
d1
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
PS
S-
PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
!) Site Classification
ORS
C14--
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �'" Title Date
SITE DIAGRAM
DCHD (6-82)
1. Permit
2. Addres
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone gW4tU. g 7
Business Phone 9/9- I7%4111d3
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homey Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of ome and number of rooms.
House Dimensions Ae a2w
Bed Rooms— Bath Rooms— Den w/Closet / m
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 garbage disposal
lavatory showers washing machine
dishwasher n sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No x
9. a) Property Dimensions
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
ru
DCHD (6-82) ': ,
DAVIE COUNTY HEALTH DEPART11ENT
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 FORM
LOCATION OF PROPER :
DATE RECEIVED
(office use only)
yes no (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described property, however, I
j certify that I have consent from ,owner to
tt owner's Hama
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
ll Davie County Health Department to enter upon the above described
_ L property and conduct all testing procedures necessary to
determine its suitability for a ground absorption sewage
disposal system.
34-Y
DATE
js&lz zjp,�—
SIGNATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results.from the above described property to the
following:
341- it
DATE
+�
is -
SIGNATURE
0 Owner Only
r3 Owner's designated representative
MAnyone requesting results
Only those listed below