P5273 Riverdale Rd DAVIE COUNTY HEALTH DEPARTMENT
* 06
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
9.
`N07E:•'Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules 10 NCAC 10A .19x334-.1968) Permit Number
Name s s. + raj \` y W .`� `��— Date U. - I� b� N2 t7
L�cation ,\ �C' \ �. ��rl fi��c�.��a �.��7 t� L. Cl
ubdivision Name / Lot No. Sec. or Block No.
r� t/ Mobile Home _ Business Speculation
• v Lot Size House
No. Bedrooms No. Baths_ _ No. in Family 14
Garbage Disposal YES ] NO
Specifications for System:
Auto Dish WasF 6rYES ( N0
Auto Wash Machine YES` p'' NO fl
Type Water Supply - �-. 0 Q`A
y
'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.
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Final Installation Diagram: System Installed by
Certificate of Completion ` �-�rJ\\� Date11
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'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 PERMIT
Davie County Health Department I �VG
Environmental Health Section CCr (�
P. O. Box 665 �y
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone -2-0 Z 'S4
1. Permit Re nested By D401,r& U0&0WSy-1 Business Phone
2. Address A WL' n 5 E (A - '� oL
3. Property Owner if Different than Above F�� 7"�s qf A-a.N(c._
Address Mocks of Ile
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: House-S.Mobile Home Business
Industry Other
b) Number of people 4151RIS
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions '1700 S% f
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 Private Community
b) Has the water supply system been approved? Yes k No
9. a) Property Dimensions I ACX-'--
b) Land area designated to building site
-Q—
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? bib
Whattype?
This is to certify that the information is correct to the best of my knowledge.
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Date Owner Signature
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)
THIS IS TO CERTIFY THAT ON THE--a-ZL_DAY OF ,�Ty�y 11i I, SURVEYED THE PROPERTY
� £HO,WN ON THIS PLAT. AND THAT THE TITLE LINES AND THE WALLS OF THE BUILDINGS IF ANY ARE SHOWN
•HEREbN. it
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NOTE: LOT LINES SUBJECT TO EASEMENTS OF RECORD. �•`��„s' f,,'b•.
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SIGNED_
CHARL E. ON REG vg1EDISURVEYOR
N. C. LIC_EN6K 4L-I EE =
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SURVEY
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THE PROPERTY OF
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MAP RECOROE_ O IN-8-00-K_ _AT PAGE DEED RECORDED IN BOOK _ PAGE. 3.6y
F.B. C:w P.G7
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ✓ g�'p �1� 4 0 W S �1 Date - FSr
Address Lot Size A cp-&.
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS, PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Titles+- �� Date
SITE DIAGRAM
DCHD(6-82)
Page
F.F. NamJ
DATE NOTES Z"oSI WATURE
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'27 rn
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- � a
N. C. State Board of Health, Form no. 278, rev. 3/58
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
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: . DATE RECEIVED
"t�-t 4, �x3
2c k0Qt- L4tt-L� (office use only)
R%UERD c RD EPo.Akey ,t w�
yes 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 I 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.
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
Anyone requesting results
Only those listed below
DATE SIGNATURE
DCHD(11/84)