P5350 Gladstone Rd DAVIE COUNTY HEALTH DEPARTMENT Aso- r3o
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) 1Permit Number
Name Ls o\, Date I b ' 3 1 '� N2 5850
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size b° °" House Mobile Home _ Business Speculation
No. Bedrooms No. Baths - No. In`Family
Garbage Disposal,,. YES ❑ NO ❑ Specifications for System:
Auto Dish Washer x°� YES ❑ NO ❑ 0 o v ��,
Auto Wash Machine YES ❑ -NO. ❑ .3 u� \r x , 1`►
Type Water Supply
*This permit Void if sewage system described below is riot installed within 36 months from date of,,issue.
�.\ K
yL. Improvements permit byC\`\ �
tl
*Contacta 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
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.
` 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. /
Home Phone �J Y 05z-
1. Permit Request By �� ✓ ( ��� � Business Phone l �
2. Address )M✓ '
3. Property Owner if Different than Above (55:` N'e t
Address
4. Permit To: a) Install tn-_`AIter Repair
b) Privy Conventional her Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home es
IndustryOther
b) Number of people �-
6. aT If house or mobile home, state size of home and number of rooms.
House Dimensions ,��u -7 0
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 2- urinals garbage disposal
lavatory Z showers washing machine
dishwasher sinks -� *?
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes ►L'No
9. a) Property Dimensions -2 D D 7� !!=0 0
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 corr to the best of my knowledge.
DatOwner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMP CE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
ocwo(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
// (office use only)
Z.CI"r�S 41V 12 I��
es no 1. I 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
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.
C�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.
DAtt SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
Ow�ers designated representative
nyone requesting results
— Only those listed below
i
U
ATE SIGNATURE
Adr-
DCHD(11/84�
t
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
\ _ SOIL/SITE EVALUATION
Name— A Date
Address U Lot Size 1
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, �� S S S
Loamy, Clayey, (note 2:1 Clay) �a� PS PS
�l s U U
3) Soil Structure (12-36 in.) S SS S
Clayey Soils ® ..� PS PS
U U U U
4) Soil Depth (inches) S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U U
External S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S S
S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLEP Provisionally Suitable
Recommendations/Comments:
Described by - Titley --- Date
SITE DIAGRAM
DCHD(6-82)