P4691 Hwy 601SDAVIE 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 NCA 10A .,1934-.196) Permit Number
Name
Location
Subdivision Name Lot No. __ Sec. or Block No.
Lot Size
House _ Mobile Home _ _ Business ��` Speculation
No. Bedrooms Z241 No. Baths ___,/ No. in Family
Garbage Disposal, YES p NO
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES p NO
Type Water Supply
*This permit Void if sewag
led within 36 months from date of issue.
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 Lg42,2,4a ��-
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.
�R
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department m.
P. O. Box 665 R G
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone Q ky-y3,27
1. Permit Requested By �0!� l'r Business Phone 5119 2k5_-,-? %M
2. Address `f c v
3. Property Owner if ifferent than Above
Address
4. Permit To: a) Install-4ZAlter Repair
b) Privy Conventional Other Type—, c.7Q ,ti
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
�
Industry Other �a r p? ✓
r
b) Number of people Qc c n fte, I 11, 14l y--AdS r C;, r e u_ t!
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 f urinals garbage disposal
lavatory showers I washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No W C61
9. a) Property Dimensions ASO Acrr,<
b) Land area designated to building site 8_!4'
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? '
_j-% c G et r r,
This is to certify that the information is correct to the best of my Riga Ledge.
� "� ( f� )
(Date Oowner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
600 t
11
/n4ri5-c(14'or"
DCHD (6-82)
4Gc,4k r 6h_ r11 )e- Gr -
y 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. 0. 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)
es 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.
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.
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
wners designated representative
Anyone requesting results
Only those listed below
7
DATE
DCHD (11 /84)
Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date���
Lot Size
FACTORS AREA 1 AREA 2 AREAS nRFe d
1) Topography/ Landscape Position
S
S
S
PS
PS
PS
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
P
PS
PS
PS
U
U
U
U
il) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Spaceis
S
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
)) Site Classification
,/
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments: -
Described by
SITE DIAGRAM
DCHD (6-82)
Title
Date