1859 Yadkin Valley Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
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 NCAC.10A .1934-.1968) Permit Number
Name s WFZY6 7-Date -RS 'i`JC TM 3'2
Location I W ! -7-6 i2 >. -72
i2 7. I.eft� .. �
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths I No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System:/ -
Auto Dish Washer YES ❑ NO [:] r
Auto Wash Machine YES ❑ NO '❑
Type Water Supply v-i
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
&L
�1Zort
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.
Final Installation Diagram: System Installed by1J�
1 .
--r-�certificate-of'C'ompTetion Date
/4 W
*The signing of this certificate shall indicate that the system described aboy� has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken tas a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Namea>/ArNr- &3&66 Date
Address -E310 6E-93N� Y r'� Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
b PS PS
U .T, U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) '(M PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils (215 PS PS
U U U U
4) Soil Depth (inches) S S
pS (PS PS PS
U U U
5) Soil Drainage: Internal h S S
PS PS
U '�� U U
External S S
b) 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
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLEPS—Provisionally Suitable
Recommendations/Comments:
Described by Title ����7 -rLt/+-�/ Date ,F`
SITE DIAGRAM
x
DCHD(6-82)
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?` 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 ISSUED.
Home Phone��
1. Permit Requested By Business Phone
2. Address 2 D
3. Property Owner if Different than Above c
Address /T?.D er/ e '
4. Permit To: a) Install vAlter Repair
b) Privy ConventionalyOther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House—4---Mobile Home Business
Industry Other
b) Number of people—'
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 2 -7 ,K3 r
Bed Rooms z 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 07.e_� urinals garbage disposal
lavatory P showers washing machine'
dishwasher sinks
8. a) Type water supply: Public Private X___ Community������ � y fes. �. `Qrp
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions -foo X /O o o
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?
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:
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cfs
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DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
2. Along with the form, remit the amount due as shown on enclosed statement.
3. , Carefully follow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE 14UST BE DONE BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARTriENT,P.O. BOX 57)
(140CKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTYXNT
SITE EVALUATION CONSENT FORM
LOCATION OF PROPERTY: ,�. �/) DATE RECEIVED
�p per 80 / ���� �2 (office use only)
yes notep (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described prope 'y, however, I
! certify that I have consent from owner to
} awn Is name
obtain a site evaluation by the Healt Department for the purpose
of determining the suitability for a ground absorption sewage
disposal system.
yes no (3.) S 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 necessary to
determine its suitability for a ground absorption sewage
disposal system.
DATE SIN TURF
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
Owner Only
&/�� Q3 r3 Owner's.aesignated representative
0j A yone requesting results
DATE Only those listed below
SIGNATURE ,
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