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129 Hepler RdDAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION i *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 ,"T > i��;✓t'% %; / t-�" �' /' >_ `f Date Location Subdivision Name Lot No. Sec. or Block No. Lot Size AXIV House Mobile Home _ Business Speculation No. Bedrooms No. Baths Z No. in Family Garbage Disposal YES .0 NO p-' Specifications for System: Auto Dish Washer YES NO Auto Wash Machine YES NO Type Water Supply1,6011 *This permit Void if sewage system described below is "not installed within 36 months from date of issue. 9 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 4'z/6,2.lef-2i o Certificate of Completion —11 –�--- Date Q� *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. Name— Address DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Date Lot Size .L C FAr:TORR AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/ Landscape Position S S S ( S� PS PS PS U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) S PS PS PS U U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS PS U U U I) Soil Depth (inches) S S S S PS PS PS U U U i) Soil Drainage: Internal S S S S S PS PS PS U U U External SS CP PS S PS S PS U U U U i) Restrictive Horizons Available Space © S S S PS PS PS PS U U U U � I) Other (Specify) TIP R P��' U S S PS S PS S PS J PS U U U U 1) Site Classification U—UNSUITABLE Recommendations/ Comments: S—SUITABLE PS—Provisionally Suitable Described by 22: // Title Date f% SITE DIAGRAM DCHD (6-82) J • i' APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT ,� 1 Davie County Health Department ��jj Environmental Health Section P. 0. Box 665 G3 0-11 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone Q i -i3 I R 7 1. Permit Re uested By Q(�_dr]T Business Phone q4 — 3 2 0 2. Address I a 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 Business Industry Other b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions aV t3__� 1k 4--F, .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 urina+ls' ' garbage disposal r. / N.\ lavatory showers t washing machine dishwas er sinks ' 8. a) Type water supply:,Public Private ✓ community b) Has the water supply system been app"roved? Yes No {� 9. a) Property Dimensions A OL -Q. -V- e--:5 b) Land area designated to building site2 k - Q. e."5 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. wn,, Date Owner Sig e OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: id-Z�7,cQe-. 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 C316�� (office use only) yes no 1. 1 am the owner of the abov- 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 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.. DATE SIGNA'FUWJ 4. 1 hereby authorize the Davie County Health Department to release site evaluation resup from the above described property to the following: s� Owner only — Owners designated representative Anyone requesting results Only those listed below r DATE SIGNATURID DCHD (11 /84)