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1526 Peoples Creek Rd .. _ .. ., _ _ __ _ .. . _ �—� `�J�� DAVIE COUNTY HEALTH DEPARTMENT . 1_.; d ^_�;� . •- � IMFROVEMENTS �PERMIT AND �CERTIFICATE OF COMPLETION � �.NOTE'Issued:in Gompliance with��G:S. of NortF Carolina Chapter 130 Article 13c � .. � - Sewage�Treatment anB Dpisposal Rules io Ncac.ioa.i9sa-.isse)� Permit Number 'Name.� iJy'/✓/ ��.�6 - ��/ � , �� <i/n �j� N4 �5541 Location /d"�/ %e ��//i. � /oir,✓ !�/✓1!)�r/i..,l"- !�/✓' ' A'N �� P �,r�/�1o,t.f =-- _ — Subdivision Name -.Lot Na .Sec. or Block No.. '�Lot Size .House �� Mobile Home _ Business Speculation � No: Bedrooms `� No. Baths.� No. in Family,� � Garbage Disposal YES p ��NO ❑ �Specifications for System� � ��v Auto Dish Washec YES� (� �NO p /DOD� . /�'�l y� Auto Wash Machine YES� m� �N/O ❑ ��t� q� JJ7� y �/Y � . Type Water Supply /c� _ v UU n`� /� /� , `This permil Voitl..itsewage system describetl'below�-is not'installed within 36 monlhs from tlate.of issue. / V Improvements peimit by —! Y�7�a �� 'CoNact�a representative otdhe��avie Counry��Heaflh DepartmenC for final inspection of .this system between 8:30- i 9:30 A.M. or 1:00-1`.30 P:M. om�day of completion. Telephone'Number: 704-63d-5985. � Final Installation Diagram: System�lnstalled�by (��+ hrnn�i� - 4 d II ' `.y . . Il 'P. I , ; � � o �� , �'� �/ p � Cenificate�otCompletion- �` �a/� Date ��l�n�� ` �� 'The�signing of ihis certificate shall'intlicate��that the system tlescribed.above has been installed in compliance with �� the�stantlards se(��forth m.the above regulation, but sBAll.in�.NO waybe�takemas�a�guaranteeYhat tfie system wilLtunction `\actorily for any given�period of time. . � , t �.' � . , { ' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department � a � Environmental Health Section �CE1V�0 APR P. O. Box 665 � Mocksvil�e, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. � Home Phone a��`�Q�"�� 1. Permit Re� sted By '4 �-' Business PhoneQ�Q'��-�I� 2. Address �� 98 I C lern o1�} Al�� dI�I1Ji� 3. Property Owner if Different than Above ��1hnt I�o�S S�r.� �Noo`4"S Address �.��Oti.!-.SA�Cm lt�� 4. Permit To: a) InstaIlJ�Alter Repair b) Privys�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 , 6. ar If house or mobile home, state size of home and nu ber of rooms. House Dimensions � � �f� a �� ' Bed Rooms � 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_s�Private Community b) Has the water supply system been approved? Yes�No 9. a) Property Dimensions b) Land area designated to buildin site c) Sewage Disposal Contractor 10. Do you anticipate any additions or expansions of the cility this sewage system is intended to serve? � What type? This is to certify that the informatio is correct to th best of my knowledge. f �� `�� ate O n Signature OWNER IS SOLELY RESPONSIBLE FOR COM LIANCE WITH AL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: o s�,°/% f�-�� o..e�� d� � � l� � � e ' �t �0 / �=� � /s � �� y�-_ , mu,� �, � ��a� �� .�� _ . � ti � � � �.�� , � �� -� �� . � � r � � �., .� -�, -;F�.. �_ .� �, �. .�.� DCHD(6-82) � ` , � 1,• . , ' � ` DAVIE COUNTY HEALTH DEPARTMENT ENVIRONMENTAL HEALTH SECTION � SITE EVALUATION CONSENT FORM 1. Complete the form below and return to the Davie County Heaith 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 PECEIVED / � RQQ�I�., n - �Y�J (office use onlY) 1 �.�� yes no 1. I am the owr�er of thE above described property. � no 2. I am not the owner of the above described property, however, I certify that I have consent from__ �O il1 f�� , 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. es no 3. I 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. -/7- ' c� DATE IG TURE 4. I 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 _Anyone requesting results �Onl those 'sted below _� DATE SIGNATURE DCHD(11/84) , , t � , � '� 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 �� 5� � � PS �S U U U U 2) Soil Texture (12-36 in.) Sandy, S Loamy, Clayey, (note 2:1 Clay) � PS S � U 3) Soil Structure (12-36 in.) �� S S Clayey Soils / PS�� r% ' �� _� -'� U 4) Soil Depth (inches) -� �� PS � (PS) . (�C1 U U l?� 5) Soil Drainage: Internal . <-Ji� S �- S P �` PS U Externai �--x-� �--� � C� <r b�/ /�� 5� 6) Restrictive Horizons 7) Available Space � S S PS , PS PS S U U U U 8) Other (Specify) S S S S PS PS PS PS U U U . U 9j Site Classification � � U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable �_ Recommendations/Comments: � Described by - � Title <�� Date � SITE DIAGRAM . 1 � � �-1 � D Ih 82)