209 River Road Lots 12-13DAVIE COUNTY HEALTH DEPARTMENT
P. 0. BOX 57
14OCKSVILLE N 702
(704) 1�34:'
�9�S/
Statement for Septic Tank Improvemel Permits
and/or Site Evaluations
NAME DATE ISSUED
ADDRESS PERMIT NO.
Explanation of charge l > f,�rrr �,{/'�.1. l �,�1/t �e--
AMOUNT DUE,1"21/.' SANITARIAN
I" I I
PLEASE REMIT THE ABOVE AMOUNT 014 RECEIPT 0 - F THIS - STATEMEWT.
�DAVIE COUNTY HEALTH DEPARTMENT
�?e e-A!" Cc47-
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION - I
ote: Issued in.Compliance with G:S. of North Carolina Chapter 130—Article'13c.
Permit Number
Of-
. i .ii�f.%,2L�e�i -t. 7i � •( '�G`7fiZ r,). ,/ % t..( i
1 �' - ^ it
/Name r ,� ° r Date, t o` r tr t� 21,07
Location
I li
Subdivision Name �I Lot No it Sec. or Block No.
Lot Size • -E-<II House `Mobile Home _ Business Speculation
r� 21� Z
No. Bedrooms No. Baths No. in Family
Garbage Disposal~ +jYES ,0 NO .p.=. II 1
Specifications for System: ; I
Auto Dish Washer ! YES Q NO : ❑ -,� ' I; f ;i
Auto Wash Machine �-
I YES .� NO ,❑ 1 ✓ I� , / �,, .(, , e
r / ;
Type. Water•`Supply.
U JJ
*This permit Void if sewage system described below is not installed within 36 months from date of issue. iJ
ii
�.. \ ; yo
I Improvements permit by 4'--�
'Contact a representative of the Davie. County Health' Department for final inspection of this system between 8:30-
9:30 A.M. or 1:001''I1.30 P.M. on>day of completion., Telephone Number;' 704-634-5985. jl
Final Installation 'Dia ram: l
9 System 1nstaI d, by
i
Certificate of Completion �' Date /
-The signing ofj[this.cer ificate shall indicate that the system described, above has been installed in compliance with
�Ahe standards set•fortjieabove regulation,•but'shall in NO way betaken as a uarantee that the system will function
torily for any riod:of �II�
—.— . -, }� •c.,.,p�..Je,Z�kt�A�:.'.e'Jr'�ir�'lt��"��'1'.`r'c['y ;�pin?d. iPA. y�. 7h .Fa`.i:�'.-�•:�'._.,�-¢r- - - -� �. �
i DAVIE. COUNTY HEA TH DEPARTMENT �I
.IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION' /
NOTE. Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage T eatment and Disposal Rules .(10 NCAC 1934-.1968) Permit Number r
Name �iC/i✓'Jy �l'i .r`�� Date 4 N 4.:
Locationi,�1',r S - / '....rr !✓f>/l��. ,.tet %� .'�!%rr�I f� ;
Subdivision Name f� '`�/T�✓:'� f Lot No. n� Sec. or Block No
1,
Lot..Size ,` House _ Mobile Home _ Business -- Speculations;
No—BedroomsNo Baths No. in Family
II
Garbage Disposal , 11, . YES NO 0- Specifications for System: '
Auto Dish Washer- y,. YESi❑ . NO p
Auto Wash Machine i YES NO ;Q , fl
Type' Water Supply
I4 "
This permit Void if sewage .system described below is not installed within 136 months from date of issue.
}
Improvements 'Ipermit by !
"Contact a rep resentative.of the Davie'County Health Department for final inspection of this system between 8:30-
--9.180. A.M. or 1:00 1:30 P.M.' on day of completion. Telephone Number: 704-634-5985.
Final Installation'Diagram System Installed !by r v�
q =.34
a = Ce Cate of Completion ` _ �! Date b
u —
•' #The. signing of this certificate shall indicate that the system described above has been installed in.compliarice with
the standards set forthin the'above regulation, but shall in NO way be taken as a•guarantee that the system willfunction
satisfactorily for any giyen period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
• Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028 R�(,
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit F
2. Address
3. Property
Address
Home Phone
4. Permit To: a) Install X Alter Repair
b) Privy Conventional -Z- Other Type—
Groun4 Absorption (I
(jL1—
c) Sub -Division � �gC.Lot No.
5. System used to serve what type facility: House x 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
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 (
lavatory —
dishwasher
I
showers
sinks
garbage disposal
washing machine Z
8. a) Type water supply: Public_ Private Community
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensions .2'7&),X 12sX X �� Q
b) Land area designated to building site
c) Sewage Disposal Contractor J
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.
'�Z�
ate Owner Signatu e
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
15�1
' 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
6 1 � -) �5, (office use only)
yes no 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 , owner to obtain a
owner's dime
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 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.
e/ 77
ATE SIGNATU
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
Anyone requesting results
Only those listed below
r
ATE IGNATURE
DCHD (11 /84)
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 -
1. Permit Requested By v �G Business Phone
Z. Address
3. Property
Address
4. Permit To: a) Install" Alter Repair
b) Privy Conventiona'I"— Other Type
Ground Absorption X, _
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people a
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 i
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�a_ bAbd
^'
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? Nn
This is to certify that the information is correct to the best of my knowleCM.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAV�✓;
Allow 5 days for processing v
Directions to property:
IL
DCHD (6-82)
0
G/ Q
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date -"K
Lot Size
FAr.T0P.q APPA i ARFA 9 ARFA'A APPA d
Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
C/;f ro-
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
Soil Depth (inches)
S
S
S
pS
PS
PS
PS
U
U
U
U
Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
�) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
U
U
U
U
o) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
►) Site Classification
, �e
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE ( PS—Provisionally Suitable
Described by Title Date Y
SITE DIAGRAM
DCHD (6-82)