234 Feed Mill Rd j'Q * DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issue in Compliance With Article II of G.S.Chapter 130a — ----=�-f
Sanitary Sewage Systems: Permht Number
Name_�ry //l//�in�n l�.yS�t�,r.�?��i��n�,, Date N2 6236
Location
Lr z/ -eed'Iwx Pd
i
Subdivision Name Lot No. Sec. or Block No.
Lot Size 'Z House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO p--- Specifications for System:
Auto Dish Washer YES 4 NO ❑ �dD�, X ,,
Auto Wash Machine YES [fj NO ❑
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.
}
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 z ~�
�lO
J
i
Certificate of Completion fG 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.
DAVIE COUNTY= HEALTH DEPARTMENT
IMPROVEMENTS PERMIT .AND CERTIFICATE OF COMPLETION
t ,. ),
'
*NOTE:Iss�led in Compliance With Article Il of G.S.Chapter 130a -"- -- ;. I.
Sanitary Sewage Systems Permit Number
ZZ-gcI �> ' 6236
Name ,1.1�/hr�� .�"'t%�t°x,?_fir-�j<:r;�.-,� Date /��./J -.��' NO
Location/5 Z F�9Z
Subdivision Name Lot Nol, Sec. or Block No.
Lot Size Z House Mobile Home Business Speculation
No. Bedrooms No. Baths L_ No. in Family _
Garbage Disposal YES ❑ NO p'' Specifications for System:`
Auto Dish Washer YES 4 NO ❑ �Gd.�;�X ,,
Auto Wash Machine YES [ij NO ❑
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.
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
t
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.
r
APPLICATION FOR SITE EVALLI MPROVEMENTS PERMIT
(} (� Davi e t artment
! �y K� En me section RECEI�E
Xa' ox 665 Q NOV/
✓✓�� ,w�n111�"� Mocksville, N.C. 2702899
rl V CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 4 - 058
1. Permit Re ested My rftfr Wed burr) Business Phone r1® -7 -33(
2. Address Vi ! O)C `j� �a� '.Fi<? 1' 1S fes• ar7O(a �
3. PropertyOwner if Different than Above '117 �
Address int.
4. Permit To: a) Install ✓ AZ_1_/ 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 leo, Business
IndustryOther
b) Number of people
6. aj If house or mobile home, state size of home and num f rooms.
House Dimensions SIX'96 "�r
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 urinals — 10 garbage disposal—
lavatory ^ showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes '�No
9. a) Property Dimensions 3(D ) X 3a I x .31� .
b) Land area designated to building site 1. 51 AQ-.-
c) Sewage.Disposal Contractor Nf 6+ Sure. je-t
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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w bi� eCtSf -{� QINJ on Feta i11E II lec
prolEW,r4i on
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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. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
ed (1 it V'\98� Lbi '4
(office use only)
yes no 1. 1 am the owner of the above described property.
es no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from-:�-ohn :n7oncS 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.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE GNATUR
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
7— Only those listed below
Cahn �o�-h
r)oy.-a qq-al ql
DAYE SIGN URE
DCHD(11/84)
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