1218 Peoples Creek Rd DAVIE COUNTY HEALTH DEPARTMENT
f IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliar�eWffih,G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules ,(10 NCAC 10A .1934-.1968) Permit Number
ll
Name /' �. �; -- > ,l ti'%r ` 1 Date ��. `1`" n ,: see
Location 1 l ,+ i✓."i — �: <.. _ ;,- i:s* % — ,��!:
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business -- Speculation
r--
No. Bedrooms — No. Baths �J No. in Family _
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑
Type Water Supply
`This permit Void if sewage system des nbbd below is not installed within 36 months from date of issue.
LTi �•
1"
Improvements permit by
*Contact a representative of the D�vie Co my �ealth Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on play of on
�letion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
Certificate of Completion '` ��= Date✓'�f� w
"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 g'�MIT
Davie County Health Department C8,VE
Environmental Health Section Q
R O. Box 665 U� 1
Mocksville, N.C. 27028 7
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 7G�' S86U
1. Permit Requested By /,/'x�- Business Phone
2. Address D /e1V
3. Property Owner if Different thanbove
Address -� 9✓ � �C
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Se Lot No.
5. System used to serve what type facility: House Mobile Home Business
—
Industry—Industry Other
b) Number of people 4
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions yel.X e.10
Bed Rooms 3 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 wat r-using fixtures:
commodes urinals D garbage disposal
lavatory 5 showers 3 washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 'C &P-63
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?
What type?
This is tothat the information is correct to the b st k I e.
-71,.-- c7.7
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
/V• �'. 801 Ta
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
r 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
T
A NOF DATE RECEIVED
ff��// a ,?c (office use only)
yes no 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 61 y& , 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. .
6;1 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.
IDAYE SIGNATIJE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
Wners designated representative
/Anyone requesting results
Only those listed below
DOE SI MQfJ RE
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section.
P. 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
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S S
pg PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
p PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS
U U U
8) Other (Specify) S S S S
PSI PS PS PS
U U U U
9) Site Classification rl) -� I
U—UNSUITABLE S—SUITABLE CPS—Provisionally Suitable
Recommendations/Comments:
Described by ';C / Title Date
SITE DIAGRAM
UCHD(6.82)