P6364 Main Church Rd T� '�,.c*r.tia 5" ,r • � i,' •t.r..'1' f":HN2 > a-':.w i, ._. - .. - o •o�/ �'
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION u
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name-- ��r �.�� �s.�-r' 1 Date i� � NO
",f _ �,r
Location
f
Subdivision Name Lot No. Sec. or Block No.
Lot Size �/�7/' House Mobile Home tf::f Business __ Speculation
No. Bedrooms No. Baths " -? No. in Family
Garbage Disposal YES p NO Specifications for System: ;
Auto Dish Washer YES g NO p
Auto Wash Ma.hine YES J NO ❑ ,, QDG ' `"� � _
V r-
Type Water Supply /lr"✓f1''
*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.
F
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 t g System I Ins allation Diagram S stem Installed by
F
i
Certificate of Completion _,L� Dated. '1
*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 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
Mocksville, NC 27028ECpyE,p APR
1 . Application/Permit Requested By
Mailing Address `J�� -�r� C G% / J� xil
C.
Home Phone(ye f���� �y Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : C] General Evaluation 0 S/Tank Installation
5. System to Serve: House �bile Home 0 Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lott
No. of People Z Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
6--washing Machine J Dishwasher 0 Garbage Dasposai
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 ePrivate Q Community
9. Property Dimensions
10. Sewage Disposal Contractor
(_A1 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes X No
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 the
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
Date Signature
Directions to Property :
It r1ey
my
C
DCHD (10-89)
l
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
(office use only)
,fep 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.
yes no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described propertyand conductall
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
i
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
yone requesting results
— Only those listed below
DATE SIGNATURE
DCHD(11/84)