329 St Matthews Rd (3) DAVIE: COUNTY HEALTH ,DEPARTMENT
r -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?NCAG 1'OA .1934-.1968) ,;_. Permit 'Number ;.
Name �> `II — Date ,/^� Zk7 4046
• Location
71
Subdivision Name I! Lot No. Sec. or'Block No.
Lot •Size. /
r'fAl House Mobile.Home Business _ Speculation
No.-Bedrooms No,-Baths i No. in Family
u` - - -
Garbage Disposal YES NO
,i Specifications for System: _
Auto Dish Washer YES NOI ❑ ,` ' ��•
vUv r
Auto:Wash Machine , YES NO ❑ y
Type Water Supply, :--
'�
"This permit Void if.sewage system-described below is not installed within 36,months from date of:issue.
Irriprovements permit by
'Contact a representative of the Daviel County Health Depa�tment'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: Y,.• ` - System Installed by
k4,:
f F
;. r.
Certificate of Completion Date
�(
The signing of-this certificate shall;indi''date that the-system described above has,been�installed,*in,•corhpliance'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 PERMITCCO
Davie County Health Department cC��G
Environmental Health Section R
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone�'l04) R7,Z-0560
1. Permit Requested By ':I a V; �. ti✓P J Z Business Phone 70g) 433 -5750
2. Address 1272 5;MQ1nI. L A4 F 2 :S PSS NC , 29611
1 CC
3. Property Owner if Different than Above �a1T fav �afl
Address27029
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 Homed Business
IndustryOther
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 14 X 70
Bed Rooms—2 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 2 urinals garbage disposal O
lavatory Z showers washing machine I
dishwasher 0 sinks /
8. a) Type water supply: Public Private Y Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /,S 3,res
b) Land area designated to building site
c) Sewage Disposal Contractor IP,AIt�nnuipn
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A/0
What type?
This is to certify that the information is correct to the best of my knowledge.
Date O ner Sigg9ure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
tO Q- 1r4 11 5 S e a-
10,4 CL e h� �� , 0r o
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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. 0. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
a, (office use only)
�D
yes no 1. 1 am the owner of the above described property.
(Des - 2. 1 am not the owner of the above described property, however, I certify that I
have consent from .19j L)�a ,�-�- , owner to obtain a
owner's nam
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. 1 hereby give consent to the authorized representative of the Davie County
Health Department to enter upon the above described property and conduct al I
testing procedures as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
12 3
DAIE IGNAT
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
G-'6nly those listed below
-L 04LCI� IP4
za
IGNA E
DCHD(11/84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION G
Name. \N3 � N \2_ Date O�
Address Lot Size
FACTORS AR 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.) Ste, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils (AD PS PS PS
U U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal - S S S
PS PS PS PS
U U U
External S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title - Date
SITE DIAGRAM
1
DCHD(6-82)