201 Southwood Drive Lot 1ADAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTA: '11sued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treat enttand Disposal Rules (10 NCAC 10A .1934-.1968 .,_ �, Permit Number
Name d,'/��r7r,t idn c �•�� Date °c/ (, N.0 529
Location G V/......
Subdivision Name Lot No. E< Sec. or Block No.
Lot Size
House V Mobile Home
No. Bedrooms_ No. Baths No. in Family
Garbage Disposal YES C NO 2'
Auto Dish Washer YES 4 NO C
Auto Wash Machine YES CtJ NO C
Type Water Supply
Business Speculation
Specifications for System:
o)
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
*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 Diagra - '
Q � ,
D
System Installed by
Certificate of Completion— cow 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.
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 6 1. 1 am the owner of the above described property.
es no 2. 1 am not the owner of the above described property, however, I certify that I
have consent from �cw 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.
ye no 3. 1 hereby give consent to the authorized representative of the Davie County
Health Departmentto enter upon the above described propertyand conductall
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:
Owner only
owners designated representative
.rG Anyone requesting results
Only those listed below
07
DATE rSIGNATUR
DCHD (11/84)
1. Permit F
2. Address
3. Property
Address
4. Permit T
b) Privy_ Conventional ✓Other Type—
Ground Absorption n
c) Sub -Division Sec. Lot No. �ou'�k A
jw4 e-r'� S
5. System used to serve what type facility: House-iZMobile Home— Business—
Industry— Other—
b) Number of people 2
6. a} If house or mobile home, state size of home and number of rooms.
House Dimensions 3 2, A,�aS
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served —
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Sectioni+tlurh '
P. O. Box 665 .lr• • APR�R
4 W9
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fifctures:
commodes 01 urinals
lavatory 12- ° showers _ 2
dishwasher sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private Community f
b) Has the water supply system been approved? Yes zNo_
9. a) Property Dimensions6 0
b) Land area designated to building site
c) Sewage Disposal .Contractor �o,J1uie Ld.lCe4
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? lUf
What type?
This is to certify that the informaA to the best of my knowledge.
'iF T U3�, 4 140944 L c
L
Date ' Owner Sigr6fure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCEWITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
1
V.
DCHD (6-82(