132 Deerfield Dr (2) DAVIE COUNTY HEALTH DEPARTMENT :0
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) Permit Number
Name—� �:�� `, ,� `' Date
Location
Subdivis7bn Name \ Z'' Lot No. ~` Sec. or Block`No.
Lot Size House Mobile Home _ Business -- Speculation
No. Bedrooms _ No. Baths No. in Family —
Garbage Disposal YES ®' NO ❑ Specifications for System:
Auto Dish Washer YES [g, NO j r, >_ - - r'V
Auto Wash Machine YES NO ❑ �:t� J
Type Water Supply
.*This permit Void if sewage system described below is not installed within 36 months from date of issue.
I
L.'
! Improverrts iotmit by
*Contact a representative of the Davie County Healt Department for final�iQspection of this system between 8:30
9:30 A.M. or 1:00-1:30 P.M. on day of completion.\elephone Number: 70 - 34-5985.
Final Installation Diagram: System Installed by
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.
a�
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department 'VE 6 07
Environmental Health Section RECE O C�
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 911" 1(05- 788Gs
1. Permit Requested By 2WC MWS Business Phone AIA
2. Address 64ki;_ Tk W - 5
3. Property Owner if Different than Above F A SPYLL-M
Address ?,(��x_&ImIZ AOVAgcE /J L
4. Permit To: a) Install V' Alter 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 Business
Industry Other
b) Number of people rk
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions %3,000 Zak, f-i.
Bed Rooms Bath Rooms 3 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
8. a) Type water supply: Public Private ✓ Community
b) Has the water supply system been approved? Yes Nom
9. a) Property Dimensions 36_ ACtE5
b) Land area designated to building sites
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.
izli
Dae Owner Signatu e
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Is-VT C'� sed :5"f '//7-71 a ch:),ke- e
-Fa - r =
ke
7��-74-
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. 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)
yes 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 ink Ti , 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.
Doa AL,
DATE' SIGNATURIf
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
✓nyone requesting results
Only those listed below
D TE SIGNATURE
DCHD(11/84)
V
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION l
Name Date J �7
Address A IMP Lot Size
FACTORS AR A 1 ARE AREA AREA 4
1) Topography/Landscape Position S SS S
R�1 PS
U U U
2) Soil Texture (12-36 in.) Sandy, SS
Loamy, Clayey, (note 2:1 Clay) � `P� PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS
U U U
4) Soil Depth (inches) S S
':��PSPI PS
U U U U
5) Soil Drainage: Internal S S S S
PS
External S S S
PS PS
U U U
6) Restrictive Horizons — —�
7) Available Space IZZ' S
PS PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
CC U
9) Site Classification J
U—UNSUITABLE S—SUITABLE —Provisionally Suitable
Recommendations/Comments:
, Described by �' Title Date a
SITE DIAGRAM
6
0
T�
DCHD(6-82)