214 Ginney Lane Lot 11�". 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-:1968) PelrmitNumber
Name ,ki1A 3 e.�Z±� Date N2 5687
Location _ S i n ° \--, , N o \i IR c\ �, f w \t �e � c � -� 0 �2
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms ;._No. Baths No. in Family N
Garbage DisposalYE5 p ` NOSpecifications for System -
Auto
stem'Auto Dish Washer ,YES O
Auto Wash Machine YES O
Type Water Supply_—
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
ID
'Contact a representative of the Davie County Health
9:30 A.M. or 1:00-1:30 P.M. on day of completion.
Final Installation Diagram:
E..
Improvements
]I
of this system between 8:30-
J
rvi
v �
a
t
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.
1. Permit
2. Adw
3. r Ler
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028 16(0_ -�
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
By
Owner if Different than Above
/ Home Phone 76,& - 799/
`. 7�rC17eraS %.X. Business Phone _ 766 • Q7Co/
4. ermit To: a) Installer Alter_ Repair—
b) Privy— Conventional 9 Other Type—
Ground Absorption'
c) Sub -Division Sec. Lot No.
-
5 System used to serve what type facility: House2L Mobile Home_ Business—
Industry— Other—
b) Number of people
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 2 urinals garbage disposal
lavatory 2 showers washing machine
dishwasher sinks /
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes A No—
a) Property Dimensions 666 4046 x 13/.4 /aSo M 3of3 C /. 8o6 fres
b) Land area designated to building site
c) Sewage Disposal Contractor
1 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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
irections to property:
010 Z 17?1�e,fzhens f.
Seo .ea,. Ze/ ar"
Zew/s ✓i //e AIC 2776 z 3
dCHD (6-82)
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, R O. Box 665, Mocksville, N.C. 27028 .
Davie County Health Department
Environmental Health Section
Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
40,411/10
o,//io (office use only)
1441vane.4
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 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.
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 as necessary to determine its suitability for a ground
absorption sewage treatment and disposal system.
DATE SIGNATURE
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
-2L Owner only
Owners designated representative
Anyone requesting results
Only those listed below
DATE SIGNATURE
DCHD (11 /84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
\ \
SOIL/SITE EVALUATION
Name - m \�-a> M z��5 Date 0 CG
Address Lot Size C
FAr:TnRR ARFA I APPA 9 ARFA I ARCA n
1) Topography/ Landscape Position
9)
S
<-:=-1FSPS
PS
U
U
U
2) Soils 36 in.) Sandy,
Loa , Claye (note 2:1 Clay)
S
3) Soil Structure (12-36 in.)
Clayey Soils
S
S
U
U
U
U
I) Soil Depth (inches)
PS
S
U
i) Soil Drainage: Internal
PS
PS
P\
U
U
External
PS
SPS
P�
S
U
U
U
i) Restrictive Horizons
Available Space
PS
PS
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
Site Classification
U -UNSUITABLE
Recommendations/Comments:
i
Described by _
SITE DIAGRAM
DCHD (6.82)
S -SUITABLE LB E PS -Provisionally Suita e'J
Titlec�-_�c�^` Date ��
y r� DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued In Compliance With Article II of G.S. Chapter 130a
Sanitary sewage Systems%/�'r 6!: -/`1 i Permit Number'
Name ��LZ /Lg/ `el'" F_%Date S'%' 0
N_ 8009
Location 121, , , /' G - , ,1_i
Subdivision Name Lot No. Zl Sec. or Block No.
Lot Size �>)Cr — House — ✓ Mobile Home —_— Business --_ Industry
No. Bedrooms ��— :No. Baths =L-_ No. in Family Public Assembly Other
Garbage Disposal YES ❑ NO p- Specifications for System:
Auto Dish Washer YES ❑p NO ❑
Auto Wash Ma-hine YES Q 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
I
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
Improvements permit by
*Contact a representative of the Davie County Health epartm t for final Inspection of this system between 8:30.9:30 A.M.,
1:00.1:30 P.M. or 4:30.5:00 P.M. on day of completion. lephon umber: 704.634.5985.
Final Installation Diagram:
filled by
I.
k
Certificate of Completion _ Date SJ
'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.