1551 or 1553 Godbey Rd�- ---: DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
/'/NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
��4' Sewage Treatment and Disposal Rules (101N-�CAC 10A .1934-.1968) Permit
Name Number c� �, ��.��r. �: t\. t� Date 1 <'� N2 553)13
,V
Location
Subdivision.Name
Lot No. - Sec. or Block No.
Lot Size
House
Mobile Home _ l.% Business Speculation
No. Bedrooms r�
No. Baths-�.-1
No. in Family
Garbage Disposal
YES ❑ _NO ®'
Specifications for System:
Auto Dish Washer
YES 2- NO ❑
/ c� r,c� , �, =,.',. `� - �`� ' ���`• z•ar
Auto Wash Machine
YES p NO 0
`
Type Water Supply
_
jj��
*This permit Void if sewage system describbd below is not installed within 36 months from date of issue.
o
w
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
6
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.
' t APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
� Q Environmental Health Section/
P. 0. Box 665 / C
Mocksville, N.C. 27028
I CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/ Home Phone
1. Permit Requested By ��' t2 Ay ZJh I'S= ., Business Phone
2. Address 13 n V__3_2 9 /'e'9 lZ�Z l,.l �a/cs i Ile,
3. Property Owner if Different than Abovei/a� C4 -,a, t �S�
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional �ther Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home °Business
Industry Other
b) Number of people
6. a} If house or mobile home, state size of home and number of rooms.
House Dimensions / 2 )C 7 U
Bed Rooms c;�— Bath Rooms / 7Z 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 1__�
lavatory
v
urinals
showers
garbage disposal
washing machine �--
dishwasher sinks
8. a) Type water supply: Public Private Community W C_ i
b) Has the water supply system been approved? Yes -*OrNo
9. a) Property Dimensions 170 C—C i
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? AIZ
What type?
This is to certify that the information is correct a best of my knowledge.
3� g8`
Date j414•.7 r- Aea~ Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing o
�+u
Directions to property: w Y
ke !�o / f
,,�vJ bey `-�`
i
k.e r+ ig
1 fl /Z WA
DCHD (6-82)
LaZ Yy D U S t14L.
0 x
Ov�r k
r 1, DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTnRB ARFA 1 ARFA 9 ARFA R
ARFA A
1) Topography/ Landscape Position
6)
8)
9)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
t) Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Restrictive Horizons
') Available Space
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title Date
SITE DIAGRAM
DCHD (6.82)
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. I 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.
yes no 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.
//°- 99 L,)L,.�,
DATE GN E
4. 1 hereby authorize the Davie County Health Department to release site
evaluation results from the above described property to the following:
Owner only
L /
Owners designated representative
— Anyone requesting results
— Only those listed below
42
DATE
DCHD (11 /84)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
\ • ` SOIL/SIT_EE_VALUATION
Name
�`c��s W� \ g �-.� �pv \ Date Z 6
Address Amc Lot Size o�l
FA(:TnRC
ARFL1 1 ) AREAl ) AREA 3 AREA 4
APF?1
1) Topography/ Landscape Position
9)
( PS's
�}
PS
S
PS
U
S
PS
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
P
S
PS
S
PS
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
PS
rP5)
S
PS
S
PS
U
`d—'
U
U
1) Soil Depth (inches)
p
S
PS
U
S
PS
U
i) Soil Drainage: Internal
S
PS
S
PS
U
S
PS
U
External
�
U'
S
PS
U
S
PS
U
i) Restrictive Horizons
Available Space
S
S
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title ��—o�`—�� Date
SITE DIAGRAM
DCHD (6.82)