256 Gordon Dr DAVIE COUNTY HEALTH DEPARTMENT ,'- OU
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewaa�e Systems Permit Number
Name 144, 26LI Date °` �/� -� N2' 5938
Location /S r / t . ✓ 't�/j/l.+' _ % wl
Subdivision Name Lot No. Sec. or Block No.
Lot Size _//.IbM66) — House Mobile Home _1/ Business Speculation
1
No.. Bedrooms No. Baths //P- - No. in Family 1 _
Garbage Disposal YES ❑ NO Specifications for System: f^
Auto ish Washer , YES NO ❑
Auto Wash Machine YES NO ❑ C%E.�e�5r
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.'
This permit is subject to revocation if site plans or the intended use change.
17
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Improvements permit by — d
*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
Lb' A YA
Y
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Certificate of Completion Date � f
*The signing of this certificate shall indicate that the system describ `d above has been installed incompliance 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 R
1 Environmental Health Section 0 p
P. 0. Box 665 le -IN
Mocksville, NC 27028
1 . Application/Permit Requested By SCUT( ro, W. 0—o b l t y
Mailing Address I,.Jca5ono . AA/ane-p- . mc- �f7ob LP
Home Phone OM -4V4 Cg la) Business Phone ON)
2. Name on Permit if Different than Above
3. Property Owner if Different than Above 0-ALt
-�
4. Application/Permit For: 0 General Evaluation @/S/Tank Installation
5. System to Serve: (] House Mobile Home 0 Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms^ PIA Basement/No Plumbing
lashing Machine ID Dishwasher 0 Garbage Disposa.i
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: C Public 0 Private R/Community
9. Property Dimensions I DX a c)D
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes &I-Ko
If yes, what type?
*NOTE: Improvements Permits shall' be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
' Effective October 1, 1989.
This is to certify that the information provided is correct to tr:e�
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
—3 9�' /qr) `Jc-yxdAO- w . CrjIo(-Q,
Uate Signature
(1 Yk \) ► f' CUUr
Directions to Property :
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DCHD (10-89)
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: ���� �,L DATE RECEIVED
v,O'C-0aPJ� (office use only)
yes 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�►-, L4 36 16 0, l Ie, owner to obtain a
owne 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.
DAtff
SIG UR
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
wners designated representative
—Anyone requesting results
— Only those listed below
D� SIGNAT E 61,
DCHD(11/84)
Y �
DAVIE COUNTY.HEALTH DEPARTMENT
Environmental Health Section,
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��?�1 P Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position
S PS PS S
U U U U
2) Soil Texture (12.36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay)
3) Soil Structure (12-36 in.) S
Clayey Solis
Soil Depth (Inches) -- -, -S
U U U
5) Soil Drainage: Internal S� S S
-13 S7 coU
External
6) Restrictive Horizons
7) Available Space ® S
S
U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification . S -
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
• Y � �y
3
DCHD(6-82)