264 Bailey RdDAVIE COUNTY HEALTH DEPARTMENT''
IMPROVEMENTS O MENTS PERMIT AND CERTIFICATE OF. COMPLETION, .
;NOTE: Issued in Compliance With'.G.S. of North �iCa'rolirra Chapter 130 Article '13c
Sewage Treatment and Disposal Rules (10 NCAC. 10A .1934-.1968)1,.Permit Number
Name/�{ =r r�� ;. I� i! Date
11 36-'9
Location
�p j
r-AdSubdivision Name Il l' ' Lot No. II Sec..or Block No.
Lot Size .% H - se Mobile Home �---� Business Speculation
No. Bedrooms III-
NQ
�� li
�_ No. Baths �! � No. in Family
Garbage Disposal YES Nb.;fn'
Auto I� Specifications for S stem:
Dish Washer YES NO'0
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..
I i
Ili 7 `^F G•v l-' �{I .. v
I;
i� 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.
ill . G ,
Final Installation Diagram: ii System Installed 6,y'
I
I'
Certificate of Completion YV QM Date
'The signing of this certificate shall 'indicate thatljthe system described above has been installed: in compliance with
the standards set forth'in the above'regulation,'bbt shall in NO-Way betaken as a guarantee that the\system will function t
satisfactorily for any given period of:time. I il.
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. 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
S
S
S
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey SoilsPS
PS
PS
PS
U
U
U
Soil Depth (inches)
S
S
S
p
PS
PS
PS
U
U
U
) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
1) Restrictive Horizons
Available Space
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
I
i
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6.82)
S—SUITABLE __ PS—Provisionally Suitable
Title��
0 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
� 2
Davie County Health Department
JC ' Environmental Health Section
\� R O. Box 665
i Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone MKI) g0+002O
1. Permit Requested By B l hent ".E1,155F LL ,
Business Phone N lq) -705- 4Q0 I
2. Address 561"1 A'i A2U:A:' , w -5. 0 G 0-7 10 (-P
3. Property Owner if Different than Above Z Elio T : HnoT5
Z+ 0_1
Address WImin-,Y� -SmLlYl IKG
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division r�►"-4y\ Sec. Lot No
5. System used to serve what type facility: House Mobile Home
Business
IndustryOther
b) Number of people 3
6. a) If house or mo ' e h me, state size of home and number of rooms.
House Dimensions Ill x -7&
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 urinals
garbage disposal
lavatory showers
washing machine
dishwasher I sinks 3
8. a) Type water supply: Public Private— Community
C W)
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions / 000 P+ X 0460 -P
b) Land area designated to building site 40 auuo
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? NO
What type?
This is to certify'that the information is correct to the best of my knowledge.
Date ner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing a.,.
Directions to property:
15 8 $ p
9 acklo orlt ` 3e oq_A
"� �dlvr�Ce , %tos 5 � Imo' � � �--j
�J
let . C`I d ap.PAOV I ryWJJ2-9 r 4 m i
1 e 1 1 —t -U &SI aA_e--_Pd I U 5 -1) I JKZO i/D a, 9 Yar�e e.. rd.
�J JmLto 06 hWZQZ,::�?
� ► h o -ad Lnd ecL-40 C-enqcr tb �opo�l
ole �' 5 up rno" -f- cy""c
DCHD (6-82) Vv[ �/ 1 V 7'I 1 ,n
I,.
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
LOCATION OF PROPERTY:
DATE RECEIVED
(office use only)
yes -no (l.) I am the owner of the above described property.
yes no (2.) I am not the owner of the above described property, however, I
ox C] certify that I have consent from f3;pll _ 07S _,owner to
ow is name
obtain a site evaluation by the Health 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.
!�?_Z4=D-- V
DATE
W, W
�"y Mejklfty kill, Ma
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
`7/.h ��-
DATE
SIGNA
0 Owner Only
XJ Owner's designated representative
( Anyone requesting results
�1 Only those listed below