Loading...
345 Fred Lanier Rd DAVIE COUNTY HEALTH..DEPARTMENT_ I IMPROVEMENTS."PERMIT AND CERTIFICATE',,OFA-COMPLETION I=� IT *NOTE: Ishe*d in'Compliance with G.S!of; North Carolina Chapter 130 Article 13c Sewage Treatment:.and.Disposal .Rules (10.NCAC 1 O .1934-.1968) : :Permit NuM66r .Name P Date .,c 1 `t;• . G '0 1 _ a Location . (j �.:� � h •M� ^-.. !+ ` � .�'+.✓4'?•!). �'�t�"4 S���+�' \` tib•s'�.)lD ,�.ysen' kr.`C���.o--F•.��\ Subdivision Name- �! Lot.No. Sec:.or Block No. 11` Lot Size_ A3 ' _' House �{ Mobile Home Business Speculation No. Bedrooms �No.,Baths - No. in Family , Garbage Disposal YES'; NO X ; r, Specifications' for Syste Auto Dish Washer. ; YES ©r1\10 '❑ ,., �Zco Auto Wash Machine ,YES Type -Water' SuppIY `This permit Void if sewage system described below is not,installed within 36 months.from.date of.issue. 4. Improvements permit by� t � *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.- J, I'I ^ , S tern lied b Final Installation Diagram: y y, 6"," + . i dUi I LI ) ✓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 anygiven,period of time. !'' r PPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 2 Davie County Health Department Environmental Health Section P. 0. Box 665 Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone ln34- 1020 1. Permit Requested By Pit,(( Le–W I S Business Phone _(03 1- I of On 2. Address 1CM Bardotzri LL Aop - n 3. Property Owner if Different than Above Address C .*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 V, Bs IndustryOther b) Number of people 2 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 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 a urinals garbage disposal lavatory showers 11a washing machine dishwasher 1 sinks 8. a) Type water supply: Public ✓ Private Community -x b) Has the water supply system been approved? Yes ✓No 9. a) Property Dimensions 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? tjo What type? This is to certify that the information is correct to the best of my knowledge. lag I-?w a..'-z c), fikdt,�J • Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: go n lo'� LI-r- A-1� you- gel -�o Lc3. eCCtmp�r LLnd -4u.rvJ a4- nQ-1,+ cxi-4 on i c�V-) - go ahoM 11-e 4o Co -, le- dri.r�v`x�` wa. 14� dove l ; le road 4.0 4o G tear 64- a. i5;zk e r--)8 c,- DCHD(6-82)`�, r _• ^� n 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) yes no 1. I am the owner of the above described property. Cyes no 2. 1 am not the owner of the above described property, however, I certify that have consent from_MaraareA 64-u8eyoL4 , owner to obtain a 111) 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 propertyand 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 _t,LAnyone requesting results — Only those listed below WE SIGNATURE DCHD(11/84) s. . - ' DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section. P. O. Box 665 Mocksville, N.C. 27028 Q SOIL/SITE EVALUATION Name \ ( �'-� Date Address A 'Q Lot Size �- FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S <::*�p PS PS U U U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) PS PS U U U 3) Soil Structure(12-36 in.) S S S Clayey Soils S PS PS U U U U 4) Soil Depth (inches) S S PS PS U U U U 5) Soil Drainage: Internal S S (:11PS PS PS U U U External S S l PS PS U U U U 6) Restrictive Horizons 7) Available Space S S PS � PS PS U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification S U—UNS (TABLE S—SUITABLE PS Provisio It Suitable Recommendations/Comments: Described by Title Date b- SITE DIAGRAM �J DCHD(6-82) ...�