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DAVIE COUNTY HEALTH DEPARTMENT -°(�--
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IMPROVEMENTS PERMIT AND CERTIFICATE,..OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit. Number
Name 41?1 'rJ t e% N\Z Date —9-'a�'G'� — N0
f r 6535
/� /Location �% '"' �F 0-O�v Jt:.O-F !7 �a fit" �� i�1 �t G� P, �/ rh rr
20
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home — _ Business Speculation
- 5
No. Bedrooms No. Baths — � No.,i_n Family
—,�—
Garbage Disposal YES ❑ NO 2-
Specifications for System:
Auto Dish Washer YESNO ❑
Auto Wash Ma.hive YES El NO}' Q
Type Water Supply _
*This,permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
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Improvements permit
t 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.
Final Installation Diagram: System Installed by kzl%lsyt_. 7
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Oil F(P)e/ L/I
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Certificate of Completion —_f Date
*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
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit RequestedBy
Mailing Address
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Application/Permit for: ❑ General Evaluatio Septic Tank Installation
4. System to Serve: El House Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home:Subdivision Section Lot#
❑ Basement/Plumbing
No. of People �� ❑ Basement/No Plumbing
No. of Bedrooms �--� ❑ Washing Machine
No.of Bathrooms IV ❑ Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks ,
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: ❑ Public Private ❑ Community
8. Property Dimensions Sewage Disposal Contractor—=/1= I /�l✓
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes ❑ No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
41
This is to certify that the information provided is correct to the best of my knowledge, and(I understand I am responsible for all charges
incurred from t ' a 5ca I t
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 21""1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box#2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to d to mine said site's suitability for a ground absorption sewage treatment
and disposals ,l ,
bAVtY SIGNATURE
DCHD(12-90)
" APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
44 Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C.27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. t !�
r
o Home Phone d r �
1. Permit Re nested By Business Phone
2. Address o 3 �L 3-
3. Property Owner if 'fferent than Above LA
Address
4. Permit To: a) Install-Iff"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-K-'__
ome Business
IndustryOther
b) Number of people d`-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 No
9. a) Property Dimensions
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? -u
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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. O. Box 665, Mocksville, N.C. 27028
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
(office use only)
yes Q 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'W 4- W 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 Departmentto 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.
Z �
ATE 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
_�4nyone requesting results
Only those listed below
DATE SIGNATURE
DCHD(11/84)
` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �/l� Date
Address Lot Size ,
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, 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 PS PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS
U U U
External S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
11�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
J
DCHD(6-82)