136 Nature TrailDAVIE COUNTY HEALTH DEPARTMENT 3'0'.' c�
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) --
-Permit- Number
Name �� S"�c v Date 74 - - ''� ;iAf-4�3�
Location £, . n •�`�. t�
Subdivision Name i� I Lot No. Sec. or Block No.
ii
Lot Size Cy %r House) Mobile Home'-,,/ Business Speculation
w� J
No: Bedrooms.No. `Bath's No. - irr Family_
Garbage Disposal' YES .0 NO
a, Specifications for System: �I
Auto Dish Washer YES NO
Auto Wash Machine.. YES NO .❑ ( l l
Type Water Supplyi�
;i
`This permit Void if sewage system (described below is not installed within 36 months from date of issue.
M kA1 r�
Improvements permit by —
-contact a representative of the_ Davie.Uounty, 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 rmmnlatinn Talanhnna Nllmhor• Ind-RZd-RaAR ;!
Final Installation Diagram: System Installed by
;
Certificate of Completion vi ate
"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, bbt shall in NO way be taken as a guarantee that th'e system will function
satisfactorily for any given period of time. s'
✓ 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)
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
r 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.
2 1-3
DATE S TU E
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 G TUBE
DCHD (11 /84)�
Name—
Address
e
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date � � Lot Size
Size
9ZAr'Tf1RC APPA 1 APPA 9 ARFA 3 ARFA A
Topography/ Landscape Position
9)
cls!)
S
S
PS
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
efv
C:T
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
Clayey SoilsPS
PS
PS
PS
U
U
U
Soil Depth (inches)
S
S
PS
S
PS
•'
U
U
U
U
Soil Drainage: Internal
A)
S
PS
S
PS
U
U
U
External
h
S
PS
S
PS
U
U
U
U
�) Restrictive Horizons
--��
Available Space
S
PS
S
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
Site Classification
S
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
-�- I I --q
Described by Title �0. Date
SITE DIAGRAM
DCHD (6-82) Ir