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835 Dulin Rd (2) �- DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article It of G.S.Chapter 130a Sanitary Sewage Systems Permit Number Name ar �,. ,r .� � r-�N ,Date — ��,;7�- .i 5860 Location _ c�� r �,/�✓ - , J :; ', lJ {i f fhe � Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home — Business Speculation -No. Bedrooms — No. Baths No. in Family ry, — Garbage Disposal YES ❑ NO 2 Specifications for System: Auto Dish Washer YES 2e NO ❑ /.��,t Lla- ``uZ Auto Wash Machine YES [..]''NO ❑ t� y - �5 Type Water Supply 4�2 _ � �X *This permit Void if sewage system described below is not installed within 5 years from date of issue. This permit is subject to revocations i Re 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 Install by 1 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. 0. Box 665 Mockaville, NC 27028 ES S� 1 . Application/Permit Requested By „Z�r--Cl LcJ/9 Mailing Address 4— 9-_� Home Phone ���"' d Business Phone 2. Name on Permit if Different than Above 3. Property Owner if Different than Above 4. Application/Permit For: ❑ General Evaluation @A/.Tank Installation 5. System to Serve: House P,"'M obile Home 0 Business L7 Industry u Other 0 Unknown 6. If house, mobile home: Subdivision Sec. Lot# No. of People Z Dwelling Dimensions No. of Bedrooms Z Basement/Plumbing No. of Bathrooms , r Basement/No Plumbing (lashing Machine Cj Dishwasher 0 Garbage Disposal 7. If business, industry, other: Specify type No. of People Served 2 No. of Sinks No. of Commodes / No. of Urinals No. of Lavatories Z- No. of Water Coolers No. of Showers 8. Type of water supply : GA�-fublic0 Private Community 9. Property Dimensions 10. Sewage Disposal Contractor 11 . Do you anticipate additions/expansions of the facility this system is intended to serve? Yes . If yes, what type? f *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 thft best of my knowledge, and I understand I am responsible for all charges incurred from .this application. 12 - 96 Date Signature Dire^t:a.c)n� to 'Property : Al Property : . vac ate ea( - -' � At �U� YLi �It �P1. � c�C� Ccc e r y Y ?�r y 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: DATE RECEIVED a�-R (office use only) 0 es no 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 , 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. ye 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. L—13-y'6 x&, DATE SIGNATU E 4. 1 hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: —Owner only — 0 rners designated representative _Anyone requesting results — Only those listed below DATE SIGNATURE DCHD(11/84) DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name /r�°2 �'� Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position © & PS PS PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) PSS, P$ -0 4$ 3) Soil Structure (12-36 in.) S S S S Clayey Soils � � aU (0 4) Soil Depth (inches) S S S S pS S -P-S e"/ 0 5) Soil Drainage: Internal S S S S PS 19 P External S PS �P) ' U U 6) Restrictive Horizons 7) Available Space is PS PS PS U U U U 8) Other (Specify) S S S S PS PS PS PS U U U U 9) Site Classification U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable Recommendations/Comments: a Described byZ Title Date SITE DIAGRAM Y v Y3 DCHD(6.82)