290 Arrowhead Rd DAVIE COUNTY HEALTH DEPARTMENT
K-' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) umber
,
Date
Names ;.., lr'•J7,.,;i 1Jf �r�. r;; 4>
t ..
Location -�/.. t' , �.r' `,,o.� /�
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business __ Speculation
rC
No. Bedrooms —_ No. Baths _ya No. in Family
Garbage Disposal YES NO p Specifications for System:
Auto Dish Washer YES NO p
Auto Wash Machine YES NO ,E]
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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 'n,.,-
Certificate of Completion Cr 1 �1<< � Date
#The signing of this certificate shall indicate that the system describeici 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:
�3
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERA`I� Q'�
Davie County Health Department �GG�
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
91-1
Home Phone 7�oS-IR9$
1. Permit Requested By � r1% Business Phone '1(aQ-090
2. Address Sn c¢, tt� �Z� . ���s�-o r.- �ix �er,�N C ,
3. Property Owner if Different than Above � �fU L
Address �� �5�� 2`1� . J; lle_
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: HouseLG Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensio 3 5 1 k y
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Indi4stry 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 3 washing machine
dishwasher sinks (n
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No r✓
9. a) Property Dimensions S G c Y� 5
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the fa 'li y this sewage system is intended to serve?
What type?
This is to certify that the information is correto the best of my knowledge.
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DatJ Owner Sig ture
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82) /��'SJ31 GY' I
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, R O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
_____ �,v;ronmcnta(J-(o�13F1_Coctinn
Site Evaluation Consent Form
LOCATION OF PROPERTY: q+2 Q,K2-.2N DATE RECEIVED
IMacks ri tie,WX• (office use only)
yes no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner off the above described property, however, I certify that I
have consent from ACLrr.( L. TiNjer , owner to'obtain a
own is 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 Departmentto 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.
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JDAT9 SIGN URE
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
--,ZAnyone requesting results
Only those listed below
DATt SIGNAT E
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date f l
i
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, �� S S
Loamy, Clayey, (note 2:1 Clay) P ( P�l PS PS
U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils (P PS PS
U U U U
4) Soil Depth (inches) S S
PS PS PS
U U
5) Soil Drainage: Internal S S
PS PS
U �� U U
External S S
g PS PS PS
U U
6) Restrictive Horizons
7) Available SpaceS S S
4? PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification ,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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DCHD(6-82)