P3200 Greenwood Lakes11DAVIECOUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Note: Issued in Gomplianee North Carolina Chapter 130. --Article 13c.
NamZi:;
Date
Name'!
Lbca tion
�1*1_ 44,kt W, 5 2�e�
PermitNumber ab�v
8ubdiVisio-n Name,Lot No. Sec. or Block No.
Hbuse�_ Mobile Home' Business
Lot Size Speculation
4
1\16.� Be'driborfis No Baths No. -in Family
.,,Garbage Diq'posal-,...-
Specifications for Sy'stbm:,
:Auto .'Dish -Washer. YESgi NO
Auto -Wash P�Iddhine ',YES -Ffi� NO ,1[]
Irf Y,
Type, Watery Sup,ply:-
� t escribed' below is not -installed Within 36 months from date of issue.,
-thi5perr-h i tVoid,:if sew'ag ell Sysem'd'
TV
IV
(v
yg
w.
b
iniprbvements permity�
*Contact a,,(jepreseniative 'of th'e, Dav'ip County Health- Department for final inspection of this system between
9:30 1 A.M. or. 1,:00-1:30. , P.M. on day ot:'complotion, Telephone Number: 704-634-5985.
FinalInstallation b.i',b oli<
System Instal
agram:' ed
V
Y,
Certificate of Completion Date
"'The signing of thI is certificate shall =indicate that the system d scribed above has-been installed in compliance with .
the standards set 6rth in the above,.reoulation, but'shall in NO Way be tal�en as a guarantee that the systern will funqtioh-,,,�,,��,
111111�cafisfactohiy for any',give'n period- -of"time.
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
INSTRUCTIONS/PREREOUISTES
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 SANITARIAPI WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO TIiE(DAVIE COUNTY HEALTH DEPAREDIENT,P.O. BOX 57)
(14OCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTIViENT
SITE EVALUATION CONSENT FOR21
LOCATIOiV OF PROPERTY:
DATE RECEIVED
(office use only)
yes no+ (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described property, however, I
R!! certify that I have consent from j?, A A-,-; /3 V rs,`�.,/,owner to
-- l� 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.) 1 hereby give consent to the authorized representative of the
i 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 SIG TURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
DATE
_--ST
. Owner Only
C3 Owner's designated representative
0 Anyone requesting results
Only those listed below
} r APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
1. Permit F
2. Address
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
3. PropertyOvynerif Dirent
Address
Home Phone
Business Phone 4-3Cl�2rL SZ
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 obile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home ndnumber of rooms.
House Dimensions—a-,-330 Sa k
Bed Rooms 3 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 2- urinals_
lavatory showers
M
dishwasher sinks
8. 'a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes_L1N
�. a) Property Dimensions 1 R_ea _ f -M -r- I
garbage disposal j
washing machine
b) Land area designated to building sit "4 k `
c) Sewage Disposal Contractor Ct-o WS
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What tvnP9
I
This is to certify that the information iZcorre tothe best of my kno ge.
p
Dat4 Own Sig Lure
i
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH 41 STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
I
DCHD (6-82)