245 Sleepy Hollow Rd -. ..-:.;.-,-.,....;::.:.aiF--^-•w2::t�.:vtY.,,,..-. .�,r,..s.. �..-"✓t<•+4 J 1...:- S, , �: .�.:r r -.... •- ••ate^ • �. 4 .:....a::mio:ti',er;::.,, ) -
DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE_-OF COMPLETION
.- 'NOTE: Issued in Compliance with G.S. of Northf`Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
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Name ,� � ; �; s'.<< , "�'� f Date c1 -✓/ . _ _� �-�
1 Location /�•� c j— f„�'1 1> :i r%i `/!' - ==J' �"'%/ /i r �.. _ r %/ .,.>
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Subdivision Name Lot No. Sec. or Block No.
Lot Size House I Mobile Home — Business Speculation
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No. Bedrooms .�'�_ No. Baths — No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES . NO ❑ t� ' %Y .
Auto Wash Machine YES j NO ❑ L� �1
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 p
*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
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Certificate of Completion f / Date
'The signing of this certificate shall indicate that the system described above h'as 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
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN f�S��'::�.7
_ Home Phone'/y 7 6-3 " 51/92–
1. Permit Requested By Jo k <<' �"�""1 scar✓ Business Phone
2. Address `f" S . dc�!SUi . G
3. Property Owner if Different than Above
Address
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- Mobile Home Business
Industry Other
b) Number of people �Dus�
6. a) If house or mobile home,',state size of home and number of rooms.
House Dimensions 7 3y�}
Bed Roomser
"Bath Rooms -') I/2 Den w/Closet
b) If Business, Industry onOthpr, 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 3 urinals garbage disposal
lavatory 4 showers washing machine /
dishwasher I sinks
8. a) Type water supply: Public Private—Community
b) Has the water supply system`been approved? Yes No
9. a) Property Dimensions J&'! X97 r Y 3-793 3 V 43-1
b) Land area designated to building site
c) Sewage Disposal Contractor 63u=cm
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? �O
What type? A
This is to certify that the information is correct to the best of my knowledge.
Date Owner Sig ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to prope
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DCHD(6-82) IR "' l�wC-
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
oFa: s�,L�►�g•-' Roaq (office use only)
PPUPDs6to S�-6EP /VULLOcu Esr-aTE
ye 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 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.
DATE SIGNATU E
4. 1 hereby authorize the Davie County Health Department to release site
evaluation res Its from the above described property to the following:
Owner only
Owners designated representative
Anyone requesting results
Only those listed below
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DATE SIGNATURE
DCHD(11/84)