P5411 Gemstone Ln - ; DAVIE COUNTY HEALTH DEPARTMENT a.3
,! 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
O t ) _ nn i
Name � a�Z\ \� \ Date . rh - �' r� N2 L� 1
Location «� U U �•
Subdivision Name Lot No. Sec. or Block No.
Lot Size `h��j House Mobile Home _ Business �� Speculation
No. Bedrooms �-- RNo: Baths No. in Family 3
Garbage Disposal. YES C NO 12,
Specifications for System:
Auto Dish Washer, YES d',NO C /. Uoc�. c
Auto Wash Machine' YES [V NO C
Type Water Supply - Q-1" .
'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 =t��� ,~ ?`��
`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
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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.
OT,Yn I IV P (CATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
f r 0��-►')Environmental Health Section D �� 1 2
5 P. O. Box 665 ��1V� l'
� Mocksville, N.C. 27028 R E
CONSTRUCTION SHALL NOT BE IN UNTIL IMPROVEMENTS PERMIT HAS BEEN
ISSUED.
/ Home Phone q!?IR%2 3
1. Permit Requested B G r .� • !2 Business Phone
2. Address d, 4,0-
/'� da,"e-_e bb
3. Property Owner if Different than Above
Address /
4. Permit To: a) Installer 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 Homes
IndustryOther
b) Number of people 3
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions y X a
Bed Rooms - Bath Rooms o2 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 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks -3
8. a) Type water supply: Public Private Community
munity
b) Has the water supply system been approved? Yes No
9. a)property Dimensions -1W Cr&u^'n)
b) Land area designated to buildin ite
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expa ions of the acility this sewage system is intended to serve?
What type?
This its tocertifythat the information is co rre t t the best of my knowledge.
Date wner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: ocKso" 1e' PC
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DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name l= A t��J �t ey Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
4:: PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) A PS PS
7
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S� � pg PS
U U U U
5) Soil Drainage: Internal S S
PS PS
U U U U
ExternalS�. S S
CPQ PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
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:
Described by �- Title Date
SITE DIAGRAM
DCHD(6-82)