P3446 Hwy 801NDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
�pwage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)Permit Number
Name 1�lt�, 1\��t�,t- Date46,
Location eC�s`fL�.�t I S< `F)Z7) C�/ty,,.•� �/ti'r': �5 f2 z G•/i c'.,�,,,
Subdivision Name Lot No. Sec. or Block No.
Lot Size ,// L3 House Mobile Home _ Business Speculation
_.7
No. Bedrooms No. Baths 7— No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for System: /Oc�o
Auto Dish Washer YES ❑ NO [Dr�
Auto Wash Machine YES E]NO ❑ ZOO A -r ,k 15' ja-V—L.
Type Water Supply , —0
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
y
r� y5
�L.3
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
byz4ofvl Zf�r'
Certificate of Completion I1. �Date
*The signing of this certificate shall indicate that the system describeUd 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
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name -IAVJ> int (`LE4 / Date . �3
Address �T Z �r Lot Size
/� i/ig-�✓Ge, C Z7av
i
FACTORS ARFA 1 ARFA 5) ARFA 3
ARFA A
1) Topography/ Landscape Position
t
(P
S
S
PS
PS
PS
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
A>
�S
(5
S
PS
S
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
(,
PS
PS
U
'L�
U
U
I) Soil Depth (inches)
(�4
S
PS
S
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
i) Restrictive Horizons
Available Space
S
S-
S
S
PS
PS
PS
PS
U
U
U
U
I) Other (Specify)
$
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PSL -Provisionally Suita le"
Described by Title
SITE DIAGRAM
qo�
Date 6 - Z - Ry
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department ,g
Environmental Health Section���
R 0. Box 665 '1
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requestt d By �Ad"
2. Address - /� f 2 o x 5
CE 4. C. 270OG
3. Property Owner if Different than Above DoE o cJe.1 f z
Address -- �%s�r�v%l�e ii • �'•
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone
Business Phone s �•� �—
c) Sub -Division Sec Lot No.
5. System used to serve what type facility: House Mobile Business
IndustryOther
b) Number of people y
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 urinal
lavatory
showers
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes :i No
9. a) Property Dimensions
garbage disposal
washing machine
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 correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
i
JD 2
o ��� ;LLE
/n �
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
INSTRUCTIONS/PREREQUISTES
1. Complete the form below and return it to the Davie Co. Health Department.
mens.
3. Carefully follow the procedures as outlined in the enclosed "Information
Bulletin".
4. Notify Health Department upon completion of item number 3.
NOTE: ALL THE ABOVE MUST BE DONE BEFORE A SANITARIA11 WILL BE ABLE
TO BEGIN THE REQUESTED EVALUATION.
DETACH HERE AND RETURN TO THE(DAVIE COUNTY HEALTH DEPARTMENT,P.O. BOX 4W)
(MOCKSVILLE, N.C. 27028)
DAVIE COUNTY HEALTH DEPARTMENT
SITE EVALUATION CONSENT FORM
LOCATION OF PROPERTY: / L
T— GHQ f° $a1 Now f%. 7FOb�Adc( �jl}RMi.T�
'000cricl ,Cof ow %y X1 6;ete o �' 144,nes P/.
�RGin9 got
DATE RECEIVED
(office use only)
yes no (1.) I am the owner of the above described property.
a� �X
yes i no (2.) I am not the owner of the above described property, however, I
certify that I have consent from Joe ,owner to
C] owner's 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
i 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.
151-S11-0
DATE
SIGNATURE
(4.) I hereby authorize the Davie County Health Department to release
site evaluation results from the above described property to the
following:
DATE
SIGNATURE
o.z
efgw- YSvg`l
L, Owner Only
Owner's designated representative
(� Anyone requesting results
C Only those listed below