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169 Rainbow Rd (2) DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 'NOT :; 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 iI Date � 4; 5 Location Subdivision Name Lot No. Sec. or Block No. Lot Size House Mobile Home _ Business Speculation No. Bedrooms No. Baths 4Xts No. in Family Garbage Disposal YES ❑ NO p' Specifications for System: Auto Dish Washer YES [p NO ❑ Auto Wash Machine YES NO ❑ Type Water Supply ;•T� _— `This permit Void if sewage system described below is not installe w'tfi'A 36 months from date of issue. 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 by]'j&rr ED-, k Certificate of Completion Date-t. '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. DAVIE COUNTY HEALTH DEPARTMENT Environmental Health Section R O. Box 665 Mocksville, N.C. 27028 SOIL/SITE EVALUATION Name Date Address Lot SizeG FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position SS S S PS PS U U U U 2) Soil Texture (12-36 in.) Sandy, S S S S Loamy, Clayey, (note 2:1 Clay) ---&V PS PS U U U 3) Soil Structure (12-36 in.) S S S Clayey Soils k5 PS PS U U U 4) Soil Depth (inches) S S PS PS U U 5) Soil Drainage: Internal Sym S S 'IT PS PS U U External S S S PS PS U U U 6) Restrictive Horizons 7) Available Space ® 6 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—SUITABLE PS—ProvisionalIv Suitable Recommendations/Comments: Described by Title /� Date / SITE DIAGRAM 14 -L { DCHD(6-82) e 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 MUST BE DONE BEFORE A SANITARIAN WILL BE ABLE TO BEGIN THE REQUESTED EVALUATION. DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARTMENT,P.O. BOX 57) (MOCKSVILLE, N.C. 27028) DAVIE COUNTY HEALTH DEPARTMENT SITE EVALUATION CONSENT FORM LOCATION OF PROPERTY: � � � DATE RECEIVED (office use only) I am the owner of the above described property. yes. o (2.) I am not the owner of the above described property, however, I f certify that I have consent from _ /,owner to f owner's name obtain a site evaluation by the health Department for the purpose of determining the suitability for a ground absorption sewage disposal system. yes no (3.) I 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. /<2 DATE G�3IGNATURE (4.) I hereby authorize the Davie County Health Department to release site evaluation results from the above described property to the following: 0 Owner Only �� ✓ Z l— �i� 3 Owner's designated representative l O nyone requesting results DATE E/Only those liste Blow IGNATURE ��� M . APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Davie County Health Department ��— /_ Environmental Health Section P. O. Box 665 JpC' �/5��1/J1? Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. Home Phone 1. Permit Requested By ,4Z ✓ Business Phone 2. Address 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 Homed Business IndustryOther b) Number of people 6. a) If house or mobile home, state size of home and number of rooms. House Dimensions 6 Bed Rooms_Bath Roomsl z 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 Z 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 �o 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? What type? This is to certify that the information is correct to the best of my kno dge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: cJ f DCHD(6-82) - 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. t r Home Phone p 9 ' �3 Z 1. Permit Requested By % Business Phone 2. Address — 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 B�s IndustryOther b) Number of people 6. a) If house or mobile home, stat size of hqrrje and number of rooms. House Dimensions—//" v Bed Rooms Bat 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 Z-- urinals Y „ garbage disposal lavatory L showers washing machine—/ dishwasher sinks 8. a) Type water supply: Public Private Community — b) Has the water supply system been approved? Yesy 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 kr�a ledge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COPLI C WITH ALL STATE AND LOCAL LAWS Allow 5 days for ro essing Directions to property: � I DCHD(6-82)