1065 Hwy 801 Sa 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 Treatmerrt and DisposalRules(10 NCAC 10A .1934-.196.8)., Permit Number
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Name �.,, c:-�.�tb... .:m�.`�s•.._�•_.>`�...rs �-.. ���.s� Date NO_
Location / r, c' i. t ra �, 5�t �' c`, - 5
Subdivision Name° c>Lot No. Sec. or Block No.
Lot Size __—_L�_ b� House Mobile Home 0_ Business Speculation
No. Bedrooms 11°. Baths _ _ No. in Famitiy
Garbage Disposal,- , Yd ❑ NO '
Y� Specifications for System:
Auto Dish Washer YE� p NO gq' Z. c7 n �, - • _ -. ,t..
Auto Wash Machine YES ® NO -❑ i
Type Water Supply -
*This permit Void if sewage system de ribed below is not installed within 36 months from date of issue.
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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. s
Final Installation Diagram: System Installed by ,-o 0! v.
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*The signing of this certificate shall indi(
the standards set forth in the above regu
satisfactorily for any given period of time
i 'Date
istalled in compliance with
that,the system will function
._ 1
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
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 ,ki d
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 Mobile Home B siness
nn Industry Other
b) Number of people ���„
6. a} If house or mobile home, st9te size of home and number of rooms.
c'
House Dimensions
Bed Rooms 3 Bath Rooms 2-- Den w/Closet�L�
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 Z- showers washing machine
dishwasher sinks t
8. a) Type water supply: Public Private Community
b) Has the water supply system been approvvel? Yes-
es 7 No
9. a) Property Dimensions �,J��1�1� pe x
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?
Home Phone }—
Business Phone
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This is to certify that the information is o t tothe a of my knowledge. ; 31�
7
Date O ner Signature
OWNER IS SOLELY RESPONSIBLE FOR CO LIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: (�
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()I Nam <' J��7 \"4 ,
DCHD (6-62)
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
(office use only)
yes no 1. 1 am the owner of the above described property.
yes ,�%1 2. 1 am not the owner of the above described property, however, 1 certify that I
have consent from�/,7z-f , 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 stability for a ground
absorption sewage treatment and disposal system. / l
/,///v
ATE
S18NATIORE
4. 1 hereby authorize the Davie CQ)fity 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 SIG -qAf U Fl 14
DCHD (11 /84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
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C�� Date
S
PS
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Address
�) Soil Tex 12-36 in.) Sandy,
LoamyQ Jaye , (note 2:1 Clay)
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Lot Size
D o X 0
FAr.TnRS ARFA 1 ARFA 9 ARFA 3 ARFA d
I) Topography/ Landscape Position�
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�) Soil Tex 12-36 in.) Sandy,
LoamyQ Jaye , (note 2:1 Clay)
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1) Soil Structure (12-36 in.)
Clayey Soilsd?PS
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I) Soil Depth (inches)S
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P
PS
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) Soil Drainage: InternalS
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Cpm,
U
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PS
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External
S
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U
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1) Restrictive Horizons
Available SpaceS
P
PS
U
U
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1) Other (Specify)
S
PS
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PS
S
PS
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PS
U
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1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title �� Date
SITE DIAGRAM%� w
DCHD (6-62)