191 Raintree Road Lot 11i
DAVIE COUNTY HEALTH DEPARTMENT.
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOME: 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 Date ,'�Z88
Location; •� ://
Subdivision Name Lot No. Sec. or Block No.
Lot Size House L4_ -_ Mobile Home _ Business Speculation
No, Bedrooms No. Baths Z2 . No. in Family
Garbage Disposal YES ❑ NO .E�" Specifications for System::
Auto Dish Washer *YES NO UI
Auto Wash'Machine YES $ NO - ,
Type Water Supply
'This permit Void if sewage system described below is not installed" within 36 months from date of issue.
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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: Sy',stem Installed by
e",Iz� a/
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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 as a guarantee that the system will function
satisfactorily for any given period. of time.
Nam
Address
FACTORS AREA 1 AREA 2
DAVIE COUNTY HEALTH DEPARTM
Environmental Health Section
P. O. Box 665
cksv' le -N.
C(lll /CITE F\/DI I IATICIAI
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Date
Lot Size
AREA 3 ARFA 4
1) Topography/ Landscape Position
S
SPS
S
S
dE:)
S
PS
U
U
?) Soil Texture (12-36 in.) Sandy,
Clayey, 2:1 Clay)
S
S
S
d�
S
PS
Loamy, (note
PS
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U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
ct
�
L1
US
1) Soil Depth (inches)
PS
®
S
<T
PS
U
�
U
i) Soil Drainage: Internal
S
S
S
S
PS
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
&
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
1) Site Classification
�U-
�, l
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S � SUITABLE
PS—Provisionally uitabl
APPLICATION FOF+. SITE E1„ekLu(krioiq/@fUIPROVEr,ENTS PERMIT
• Davis County Health Department
Environmental Flealth Section
P. O. Box 665
Mocksville, I.C. 27028
CONSTRUCTION SHALL. NOT BEGIN UNTIL tKWROVEhfENTS PERMIT HAS BEEN ISSUED.
IA-&-< - J ? 9_2 / /'p Q EXT
Phone
1. Permit Requested By�_ Busjness Phgne 919 _ .
2. Address -- --
3. Property Owner if Different than AboveYI_
Address Apj_c-Ey.�L�.
4. Permit To: a) Install. ✓Alter__ Repa !r
b) Privy_— Conventional ✓her Type—._
Ground Absorption
C) Sub -Division LLALL�eeg _ Sec._!.._-_. Lot No.—//
5. System used to serve what type facility: House,4e_-_-Mobile Horne__ Business
Industry_ Other_
b) Number of people-- 3, _—
6. a) If hOLIse or mobile home, state size of home and number of rooms.
House
Bed Rooms___2___ Bath Rooms_. �- — Den w/Closet_.—+—_
b) If Business, Industry or Other, State: Number of persons sorved
What type business, etc.
Estimate amoud-of waste daily (211 hours)---
7.
ours)__
7. Number and type of water -using fixtures:
commodes 3 —__ urinals-----..-
lavatory
rinals—_- lavatory r showers-_
dishwasher sinks_ --
8. a) Type water supply: Public_ �'riva e ____.. Community_
b) Has the water supply system been approved? Yes�No__
9. a) Property Dimensions -7—._—•--
garbage disposal
washing machine—L—_ _r _
b) Land area designated to building sit);._ s VY ? _14_ — --
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of tl)e facility this sewage system is intended to serve?
What type?
M
This is to certify that the information is correct to the best of my knowledge.
Date Uwner Signature
—Afm--
OWNER IS SOLELY RESPON:^: BLE FOR COMiLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
71 /rLoLX�� ' �( •�
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OCHC (6-82)
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 farm, remit the amount due as shown on enclosed statament.
3. Carefully fellow 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 DOP1E BEFORE A SANITARIAN WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETUP11 TO THE(DAVIE COUNTY HEALTH DEPARTMENT,P.O. BOX 57)
(MOCKSVILLE, N.C. 27028)
LOCATION OF PROPERTY:
�
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORPI
DATE RECEIVED
(office use only)
yes not (1.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above decribed property, however, I
I certify that I have consent from' „�� per=,owner to
f owner's name
obtain a site evaluation by the Heal -h 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.
DATE SIG ATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
C]. Owner Only
La Owner's designated representative
G—Anrequesting results
0 Only those listed below