3653 Hwy 801N 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-:1968F Permit Number
Name f"r>': �1 I t1 rr5 Date it-/ -� G
J .'� :45
Locations
Subdivision Name Lot No. Sec. or Block No.
Lot Size %: House Mobile Home Business Speculation
No. Bedrooms - — No. Baths / No. in Family —
Garbage Disposal YES ❑ NO ❑
Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑ err// .rrr•ff v�y/uc - ? - u'y!
Type Water Supply 5-1 t U-
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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11'
Improvements permit by
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*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
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Certificate of Completion 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �' (/ �r /� �"� Date
Address � Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position U C!:--'S-j S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U
3) Soil Structure (12-36 in.) S S S S
Clea lolls PS PS PS PS
U
4) Soil Depth (inches) S S S S
PS PS PS PS
cf5r> U
5) Soil Drainage: Internal S S S S
PS PS PS
<4;;> , J: U
External ef%71 <f S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available SpaceL� S
PS S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U /U/ U
9) Site Classification ZZ (� G�
U—UNSUITAB E S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: v /
Described byTitle `– Date
SITE DIAGRAM
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DCHD(6-82
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
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.
- Home Phone �
3 7 _
1. Permit Requested By ���� Lc) &gL Business Phone 6 �Z
2. Address Ff '8 T" 2,S"t4 At-nc ksv,l ts,,, A C. 270 28
3. Property Owner if Different than Above 164 8A,
eA 191
Address Z+"• 8
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 HomeBusiness
IndustryOther
b) Number of people 2-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 12_X(00
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 t -of water-
"in fixtures:
commodes I urinals garbage disposal
lavatoryshowers washing machine
dishwasher sinks
8. a) Type water supply: Public Private L,� Community
b) Has the water supply system been approved? Yes No
9. a) Pro erty Dimensions �f✓���P� d� I�.PPS
b) Land area designated to building site —42. X64
--------------
c) Sewage Disposal ContractorQ_/�1� 11
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.
1 If-J- _4&W4, Cf.
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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DCHD( )
DAVIE COUNTY HEALTH DEPART.:ENT
SITE EVALUATION CONSENT FORM
INSTRUCTIOUS/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 DEPARTDIENT,P.O. BOX 57)
(MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FOPTI
LOCATION OF PROPERTY: DATE RECEIVED
w (office use only)
yes no (1.) I am the owner of the above described property.
I
yes no (2.) I am not the owner of the above described property, however, I
j certify that I have consent from V1p A owner to
1 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
FT P property and conduct all testing procedures necessary to
determine its suitability for a ground absorption sewage
disposal system.
ATE SIGNATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
er Only
l
g�rner's designated representative
�Z 0 Anyone requesting results
-r--� DATE Only those listed below
too
SIGNATURE