162 Oak Tree Drive Lot 141I - n a-�'..sv.•,,.a,-..g. ww.o• y�••s.,yr� .wwp�.�;.•.cw+-y •r; —o-..- - -w -.--.. _ - .o ,.. •"„ 7
DAVIE COUNTY HEALTH DEPARTMENT
-'IMPROVEMENTS PERMIT' AND CERTIFICATE OF COMPLETION
NOTE: Issued in Compliance with G..S. of North Carolina Chapter 130 Article'.136
" Sewage Treatm11 ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name -1 t\�A h a 0 Date r� �r � 4752
Location
Sub ivision Name Lot No. Sec. or Block No.
Lot: Size , j Q House Mobile Home )f Business--,Speculation
No. Bedrooms No. Baths '_ No. in Family
Garbage Disposal iYES NO Specifications for System:
a
'Auto Dish WasherYES NO�j
Auto Wash Machine iYES N&�'t]
Type Water Supply ! --
r md *This permit permit Void if.'sewage system described below is not installed within 36 months from date of issue. .
' • ° .`� .. \�` it - ,•
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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: System Installed by
I Ii
1
kgg ' -�6y8
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.
�
'A DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
°NOTE: Issued in Compliance with G.G. of North Carolina Chapter 130 Article 13o
Sewage Treatment and Disposal- Rules (10 NCAC 10A .1034`1968) Permit Number
Name Date
Location
Lot No
Subdivision Name- Sec. or Block No.
Lot Size House— Mobile Homo Business -___-_-_ Speculation
No. BedroomsNo. Baths No. in Fomi|y_--��-_-_
Garbage Disposal YES I] NOSpecifications for System:
Auto Dish Washer YES NO`
Auto Wash Machine YES NO [-1
Typo Water Supply
*This permit Void ifsewage system described below is not installed within 36 months from date of issue.
Improvements permit by
°{}nntaucto representative of the Davie County Huo|dh Department for final inspection of this uyob*m between 8:30-
9:30 A.M. or 1:00'1:30 P.M. on day of completion. Telephone Number: 7O4'634'GQ85. '
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 oftime.
t 1
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section �4
P. O. Box 665 ��
Mocksville, N.C. 27028 1
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address
�44 Home Phone y�-F ` 73.3
`c�6� Business Phone
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub- Division 63� ^W fle-, 6& Sec. Lot No./�/
5. System used to serve what type facility: House Mobile Homel:n'—Business
Industry Other
b) Number of people 13 '
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 2 urinals
lavatory showers l
dishwasher sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private Community—
b) Has the water supply system been approved? Yes1c�No
9. a) Property Dimensions -Z 'gc
b) Land area designated to building site
c) Sewage Disposal Contractor Z�14-p-p '�,L 7co') S'a_1�p o E
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Al C)
What type?
This is to certify that the information is correct to thebest of my knowledge.
41— 7— k% "i
Date Owder 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 (6-82)
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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
(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 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.
0ye no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Departmentto 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.
7b/-7
DATE V SIGN URE
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
y -7-b-7 L4,t"X��
DATE SIGNATURE
DCHD (11 /84)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FAr.TnRC ARFA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
9)
S
PS'
S
PS
S
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
dE
S
PS
S
PS
Loamy, Clayey, (note 2:1 Clay)
P
g
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
S
P�
S
S
PS
S
PS
U
U
U
Soil Depth (inches)
S
p
&
PS
S
PS
U
U
U
Soil Drainage: Internal
S
pg
S
S
PS
S
PS
U
U
U
U
External
(�--b
AS
S
PS
S
PS
U
U
U
U
i) Restrictive Horizons
Available Space
pg
PS
S
PS
S
PS
U
U
S) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS Provisionally Suitable
Described by (z--- - Title Date
SITE DIAGRAM
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DCHD (6-82)