215 Abbey Ln : s:.: : . . . a►we coui�m Heuni o�nm�Enr
�' '� �' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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. 'NOTE: lawetl In Campllanw wllh Q.B.d NoM Caroline ChepMr 190 MkM 19c
^Sewepe Frastment �na Dhpoeai nWa (to WCAC ton .t89�-.tBBBj Permlt NII�IIWr
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r.tili! fi1'/wAAG �.e1� ����'�/�/
SubdMdon Nema Lot No. See.a Bbck No.
Lot 81ze � Hou�e_�Modle Homa Bueinsw 8pawktlon
No. Bsdraoms�No. Bslhs��No. in Femlry�
GerDepa U4poW YES ❑ NO � gp�ry�llaro for Siyalam:
Aulo UNh Wuhar VES � NO ❑ ��,_J /�.0 '
rma wwr sunpy � � � � �d�L2�XS.t�iJ'� �4��
'ThM pemitl Void II aewapa yp�m MecAhed hslow b not Insle etl wNhln 38 maMhe irom dala oi ieaue.
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i�ro�n o.rmn by
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8:90 A.M. or 7:00-1.:90 P.M. on dey oi plat . Taleplqne Numhar:704-891-59�.
FYW InMdlsUon Dlapnm: ImWted by �✓-y�
cenm�w a co�p.uoo�o.a ��r-�—
'Ths•Npninp W thle aNllata dull Indlpte thet Ihs Meam da�cdhstl abwe hu bean IMWIW N eanpllence w%h
Ihs Wnderde�sl forlh M tlie ehovs ropuWion, bul p�dl m•NO w�y be qkan r r puereMas IM Ihe eptem.wlll I�ndion
r�Hactaly lor eiry piwn perlod cf Ume.
� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
� ' �� �5�
Name ��►'-s'� � �a'�i�r'1 �' � Date
Address Lot Size �/9�
FACTORS
1) Topography/Landscape Position
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
3) Soil Structure (12-36 in.)
Clayey Soils
4) Soil Depth (inches)
5) Soil Drainage: Internal
External
6) Restrictive Horizons
7) Available Space
8) Other (Specify)
9) Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
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DCHD (6-82)
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AREA 1
�
U
�
U
.�
U
.�
U
S
.�
U
��
/� ��C/��
�
S
�
S—SUITABLE
AREA 2
S
PS
U
S
PS
U
S
PS
U
S
US
S
PS
U
S
US
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
PS
U
S
US
S
PS
U
S
US
S
PS
U
S
PS
U
PS—Provisionaliy Suitable
�.
3
_ Title ���� Date
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4
S
PS
U
S
PS
U
S
PS
U
S
U$ .
S
PS
U
S
PS
U
S
PS
U
S
PS
U
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♦
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
� Davie County Health Department
Environmental Health Section / Q
P. O. Box 665 '�(� �� _ �.���
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone �-��9-�� �� ��
1. Permit Requested By �� � �2��� �'�' Business Phone
2. Address -�13 G�-��v'!J S''f•
3. Property Owner if Different than Above
Address
4. Permit To: a) Install�Alter Ffepair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Se Lot No.
5. System used to serve what type facility: House � Mobile Home Business
Industry Other
b) Number of people Tw�
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
�,�/� /�"JU -S4 F7%
Bed Rooms �w� 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 ��'o urinals
lavatory showers 7WU
garbage disposal
washing machine o��e
dishwasher sinks
8. a) Type water supply: Public� Private Community�_ �
b) Has the water supply system been approved? Yes� No �
9. a) Property Dimensions � d c't�� `
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.
3- /3 ��
Date Owner Signature
` OWNER IS SOLELY RESPONSIBLE FOR COMPLIAIVCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
� � ^�Cj /l�2l11�l�' ��•'_�Ya' �7Jc�L'l%�P
rCf Ym /h���' ?'1 JQ�?' � p � / j�
,OjrUe �l �pp�. ,9u-�•°� lJe6r�� � ,�`'i�>?�J- L�tUd����
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DCHD (6-82)
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Ti� i/e r�,
'^"��--�— � � � DAV,IE 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 ��.� .i-...,�,�TT Date = �` , „�
Location �
_ �?/.�� o.0 l�V
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business �— Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposai YES [] NO p�' Specifications for System:
Auto Dish Washer YES p NO ❑ .
Auto Wash Machine YES p NO ❑ � �
„
- � ��'y���,�� � ., .�
Type Water Suppiy ' ,.. . , , , , .. ,. , � , � _
� , --
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
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� Improvements permit by ;
'Contact a representative of fhe 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.
\
Finai Instailation Diagram: 1` _ �� System Instalied by '
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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.