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594-596 Gordon Dr (2) 4?"F i o ,m DAVIE COUNTY HEALTH DEPARTMENT t IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION Id► 00 v "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 '� ���y r , Date 6t'";= 11 S z . . Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home —� Business _— Speculation No. Bedrooms D, No. Baths No. in Family _ Garbage Disposal, YES ❑ NO Q' Specifications for System: Auto Dish Washer YES p' NO ❑ �po p o Auto Wash Machine YES ❑- NO ❑ Type Water Supply 'This permit Void if sew ge syst m described below is not installed within 36 months from date of issue. V i; Vf\ aj T &° � /Woof 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 aaSc�St�. J� rQq - Certificate of Completion Date Ci - � *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 betaken as a guarantee that the system will function satisfactorily for any given period of time. - DAVIE COUNTY HEALTH DEPARTMENT Y /UbG 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) uu Permit Number - `> l' 5 18 Name \� �i C`�, ��{--4 \� ' Date t� �,. , Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _Y Business Speculation No. Bedrooms �-41 No. Baths r� No. in Family _ Garbage Disposal _ YES ❑ NO p' S ecifications for System: Auto Dish Washer YES g NO E] 7o Auto Wash Machine YES p- NO ❑ Type Water Supply 1 *This permit Void if sew ge system described below is not installed within 36 months from date of issue. V Improvements permit byt�_a *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 <Z) �� 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 regulatiop, 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 DepartmentD�p Environmental Health Section REQ P. O. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. /�1 Home Phone o_WIC2 1. Permit Requested By 'Do/l (��a C� ?dd/P� Business Phone N -Z17 2. AddressL I �&VQ AJ0_f✓ /t/c" 07-W& 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 /ZX 70 Bed Rooms Bath Rooms c-L Den w/Close b) If Business, Industry or Other, State: Number of persons served What type business, etc. Estimate amount of waste daily (24 hours) n�P, 7. Number and type of water-using fixtures: commodes 2- urinals garbage disposal lavatory showers washing machine dishwasher I sinks 8. a) Type water supply: Public Private Community b) Has the water supply Ustem been approved? Yes No ,✓ COckr v� WaC' 9. a) Property Dimensions 71- Q,_QJL . b) Land area designated to building site c) Sewage Disposal Contractor 10. Do you anticipate a y additions or expansions of the facility this sewage system is intended to serve? What type? This is to certify that the information is corr ct 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: —V-& %9 baLq- o,-\ DCHD(6.82) a v 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) 1. I am the owner of the above described property. yes (n 2. 1 am not the owner of the above described property, however, I certify that I have consent from.... 0� rI U �2&U� / oGcJ-ee, 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 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 Owners designated representative ✓Anyone requesting results Only those listed below DATE SIGNATURE DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name ��- \0� Date S -� Address S "k-"VIZ-N-a - Lot Size FACTORS AR 1 ARE AREA 3 AREA 4 1) Topography/Landscape Position S S PS � PS PS U U 2) Soil Texture (12-36 in.) Sandy, . S S Loamy, Clayey, (note 2:1 Clay) PS PSS PS PS �P U U 3) Soil Structure (12-36 in.) S S Clayey Soils P PS PS U U 4) Soil Depth (inches) S S PS PS PS U U 5) Soil Drainage: Internal S S pS PS PS PS (:P U U External S S p PS PS PS U U U 6) Restrictive Horizons 7) Available Space S S S p PS PS PS U U 8) Other (Specify) S S S S PS PS PS PS U U 9) Site Classification _QRS U—UNSUITABLE S— PS—Provisionally Suitable p Recommendations/Comments: ���- ��� '- ��TN\\ 9N.& Described by TitleDate SITE DIAGRAM UCHD(6-82)