905 Williams Rd (3) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
- Sanitary Sewage Systems Permit Number
Name, Date
7� Date N2 5
Location 1%; /%� �' f / �'/i` �✓' ' ' Inc rr ;��.�.7 ,, fir;"
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home — Business Speculation
No. Bedrooms Z4112 No. Baths —_�L— No. in Family��—
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES ❑ NO
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.
1
_ r -
Improvements permit by �f
a
*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
�a
Certificate of Completion Date �S
"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. 0. Box 665 p MAR lam'
Mockaville, . NC 27028 RECEIVE
1 . Application/Permit Requested By �� S ( 1)Ilyr
Mailing Address 8fa AnXrYR Q Y� e, n .(!�• o-nCJ7.o
Home Phone qqQ -a345 Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : 0 General Evaluation 81J/Tank Installation
S. System to Serve: House J Mobile Home 0 Business
0 Industry a Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
0 Washing Machine r Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type Ze
No. of People Served No. of Sinks I
No. of Commodes I No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
B. Type of water supply: �ublic 0 Private 0 Community
9. Property Dimensions
10. Sewage Disposal Contractor Uck cjter
11 . Do you anticipate additions/ex ansions of the facility this system is
intended to serve? 0 Yes 7o
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.
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 this application.
3-/D-9U
Date Signature
Directions to Property :
DCHD (10-89)
,r 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 no 1. I 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.
(ge 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.
3-lo-�y
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation res from the above described property to the following:
— Owner only
— Owners designated representative
—Anyone requesting results
— Only those listed below
DATE SIGNAT RE
DCHD(11/84)
DAVIE COUNTY.HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �� e�� Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position C15) S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, _S
Loamy, Clayey, (note 2:1 Clay) P P�
U U
3) Soil Structure (12-36 in.)
Clayey Soils 5'
U U
4) Soil Depth (inches) �
U U U U
5) Soil Drainage: Internal S
P CP' P
U
External
PS P PS P
U
6) Restrictive Horizons
7) Available Space C� .
PS PS SS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification //1
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �-rte Title Date
SITE DIAGRAM
t
DCHD(6-82)