P5793 Cherry Hill Rd DAVIE COUNTY HE ��LTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage SystemsPermit--Number
Name _ : � F. r�, '��l r" 5'�'i .ani .f Date N° 5793
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Location r �, y` r�✓� rlJ`�% ,%% Clfi�'Gf/
--
Subdivision Name Lot No. Seca or Block No..
Lot Size 114.L" House Mobile Home Business Speculation
G-'
No. Bedrooms No. Baths - _ No. in Family
—
Garbage Disposal YES ❑ NO D-- Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Machine YES Q- NO ❑
Type Water Supply
*This permit Void if sewage system described below isnot 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 Healtq 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 }
Y
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.
C i
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_ APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County-Health Department
Environmental Health Section tv _D NAV 27
P. O. Box 665 R�CiE
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone Z�S9 "Z74 3
Y 1. Permit Requested By Business Phone
V-2. Address e
.-3: Property Owner if Different than Above
Address
4. Permit To: a) InstallZ Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot,No.
5. System used to serve what type facility: House YMobile Home Business
IndustryOther
b) Number of people 2
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions—Q4 r X 2-4 '
Bed Rooms 2 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 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 S No__Z
Y-9. a) Property Dimensions- 1
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? NO
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signattfre
OWNER IS SOLELY RESPONSIBLE FOR.COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:- P'QOm AlOckSVi LL
ffwy (00l s���� , �efs s (00 1 :
7v c r\. R,s Con C� oack where. Boo w 0Cd Chi
(n:J e -Fror,-, �•e. �ac�k'� f pec
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j�OTE: Improvements Permits shall be valid for a period of 5 .'
years from date issued. Improvements Permits are subject
to revocation, if site plane or the intended use change.
Effective October 1, 1989.
DCHD(6-62)
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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)
ye no 1. I 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.
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 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 r sults from the above described property to the following:
T Owner only
— Owners 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 Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
U U
2) Soil Texture (12-36 in.) Sandy, S S _
Loamy, Clayey, (note 2:1 Clay) PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils
U U U
4) Soil Depth (inches) � � S .�
U U U
5) Soil Drainage: Internal S S� 5. rS)
( IUB
External S
U
6) Restrictive Horizons
7) Available Space S� S S�j
(1T UUP' t
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE Provisionally Suitable
Recommendations/Comments:
Described by � ,� Titled Date
SITE DIAGRAM ( �(
f3
1'
UCHD(6 82)