151 Allen Rd..+.c:.v„—«�..�..rc�..w.a+r•w..w.,�'P^,,,.,;.;. .,,,-.�,.:�. :4:+:»..,.. .,,J-.�.,- a.�<P,: .r•.e':'�b, w -:•, .. - _: .,. ..r..... ,..-c-- . .,� -.
R DAVIE COUNTY HEALTH DEPARTMENT -/4�Yq ?-10, U
' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIO;Pb�I ), v a
*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 4a.L Q0 �,.`� c>ti� k\.S:'s, Date Q '0 '.ti`I ND
1, \� (. G ��'. �, , c.�c - )1�►
Location
{y\
Subdivision Name Lot No. Sec. or Block No.
Lot Size U� t.�--�' House Mobile Home Business Speculation
No. Bedrooms 2) No: Baths r) No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer; YES ❑. `NO ❑
Auto Wash Machine YES ❑ NO ❑
Type Water Supply,; -
*This permit Void if sewage system described below is not installed within 38'months from date of issue.
1
Q
VA ►
0
w r '
-
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: 'a4k ► �rSystem Installed by
A ,
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.
4
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department a�
Environmental Health Section E ]E D OCT
P. O. Box 665 REC
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 9
40 A�rms it Req estgq& AY N eC,&1AV Business Phone
� l 4'9 C I A !14 o N 13 . , 'x'12eck 5-V=
.-3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home. Business
IndustryOther
b) Number of people 2
6. a)If house or mobile home, state size of home and number of rooms.
House Dimensions I!Z 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 2 urinals garbage disposal
lavatory 2 showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community -
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 2 o X 4 7
b) Land area designated to building site • S C y
c) Sewage Disposal Contractor hl /1 e k Soils
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /V
What type?
This is to certify that the information is correct to the best ooff�my knowledge.
89
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
& o/ hlov4k - M;1e a �LLIo 4v,• 1v
� 4 k ; Co. v ,9 /1 env �e1 .
� 0 (n G0 T7 PvD �er ^f � N I gees
C, e
/1 e k4
*NOTE: Improvements Permits shall be valid for a period of 5 .
!� years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
DCHD(6-82) - '
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SATE EVALUATION
Name �� P� cRfl �_�:��� ���1• . Date b _ `�O
Addresses-- Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S ��-�,,,
PS') < C
U U
2) Soil Texture (12-36 in.) Sandy, S S S,
Loamy, Clayey, (note 2:1 Clay) <�PS C-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
4) Soil Depth (inches) Sy S S __S
_PS PS, <-PS
U U U U
5) Soil Drainage: Internal. SS S S S
(Ps`, !I'S r`PS PS
U U . , U , U,
External S S__ _S___
S `-PS --PSI 'PS
U _ U U U
6) Restrictive Horizons
7) Available Space __S\ CS
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U _U
9) Site Classification (�
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: � � �-•-- ��' �'� ��� \,
(� v
Described by Title Title • -`*=��� Date G- 6 '57<
SITE DIAGRAM
DCHD(6-82)