P5418 Southwood Acres Lot 2 Block HDAVIE 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) Permit Number
Name i5'�� v <� •%fpr �l%Ydr /�/ /�%G'// Date Z- ?- S�;� NO
Subdivision Name Lot No. Sec. or Block No.
Lot Size House �� Mobile Home _ Business Speculation
No. Bedrooms_ No. Baths Z_ No. in Family
Garbage Disposal YES. ❑ NO 2
Auto Dish Washer YES NO ❑
Auto Wash Machine YES j NO 0.
Type Water Supply
Specifications for System:
'This permit Void if sewage 'system described below is not installed within 36 months from date of issue.
Improvements permit by ye5w
'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.
t
Final Installation Diagram: System Installed by
i
Certificate of Completion rn�° _ Date 7` 1
`The signing of this certificate shall indicate that the system describes 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
1s atisfactorily for any given period of time.
t
f
Improvements permit by ye5w
'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.
t
Final Installation Diagram: System Installed by
i
Certificate of Completion rn�° _ Date 7` 1
`The signing of this certificate shall indicate that the system describes 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
1s atisfactorily for any given period of time.
1. Permit F
2. Address
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT �f
Davie County Health Department O 9 �ag
Environmental Health Section Q So
o%
N.C. 7028 R�CE1VE
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
W- I , Home Phone 43L/-_7,V/.f,Q.
!quegted By ' "//'&,r/cr Business Phone 47
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Alter— Repair—
b) Privy_ Conventional Z Other Type—
Ground Absorption
c) Sub -Division - A -'"el 104 Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home— Business—
Industry— Other
b)Number of people
6. aylf house or mobile home, state size of home and number of rooms.
House Dimensions 3 (o X Q 9
Bed Rooms 3 Bath Rooms 2-- 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 urinals garbage disposal
lavatory Z showers washing machine
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes! No_
9. a) Property Dimensions X Z/ L X Z 5— k /S3 X Z03
b) Land area designated to building site
c) Sewage Disposal Contractor
10. 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 correctttt ttthhee best of my knowledge.
ate Owner 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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20
DCHD (8-02)
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Davie County Health Department
Environmental Health Section
~ Site Evaluation Consent Form
LOCATION OF PROPERTY: DATE RECEIVED
Southwood Acres (office use only)
Lot Block H
"yew no 1. 1 am the owner of the above described property.
yes no 2. 1 am not the owner of the above describedproperty, however, I certify that I
..,.utk...- 3
0yes
no
DCHD (11 /84)
have consent from G% / I 1%-� F mss" , 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.
3. 1 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.
DA YE SIGNATURE A,.,a, �(y
OwhcF
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
D E SIGNATURE _
Name
Address
FAr.TnRR
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Date/!�i�
Lot Size s
APPA 1 AREA 9 ARFA R APPA d
Topography/ Landscape Position
6)
7)
8)
9)
S
S
PS
S
PS
ii
"`DDD
U
U
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PS
S
PS
(U
U
U
i) Soil Structure (12-36 in.)
Clayey Soils
S
SS
pray
S
PS
S
PS
U
U
q Soil Depth (inches)
S
S
S
US
US
)Soil Drainage: InternalS
P : ,..,...
PS
S
PS
U
U
External
S
S
S
PS
U
S
PS
U
Restrictive Horizons
Available Space
S
PS
S
PS
U`���
U
U
Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
U—UNSUITABLE S—SUITABLE _P_,J—Provisionally Suitable
Recommendations/ Comments:
Described by �� `/ / Title Dated
SITE DIAGRAM
-b U) v.s
DCHD (6-e2)