P5326 Branchview Ln DAVIE COUNTY HEALTH DEPARTMENT
(10 ,
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION \
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13cAm4vfel� [ `�
Sewage Treatment -and Disposal Rules 10 NCAC 10A .193 -.1968 . Permit Number
Name 14,1 y
g P ( � )
Location
r'f(6rr
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms =2 No. Baths _ No. in Family
Garbage Disposal YES ;❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ -
Auto Wash Machine YES ❑ NO C] 1
Type Water Supply
—
*This permit Void if sewage system descr'bed below is n stalled within 36 months from date of issue.
Improvements permit by
*Contact a representativei'of the Davie County Healt Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. o/ day of completion hone Number: 704-634-5985.
Final Installation Diagram-',t� Syste Installed by, L2/21irL),W,x
L�
L
Certificate of Completion Date • E'"i
*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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section CEjWp STEP 3
P O. Box 665 RE
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Re nested By `'.mc,_ e.S Business Phone 43U- a3-S4.
2. Address .(L x 3(., �Y\"r-k5v,\\e-
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 Homed Business
IndustryOther
b) Number of people
6. ar If house or mobile home, state siz)e of home and number of rooms.
House Dimensions \y XA4
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 urinals garbage disposal
lavatory 1 showers washing machine 1
dishwasher sinks 1
8. a) Type water supply: Public_Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions S acre
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) /e"M
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
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
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Solis P PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PC
PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
P PS PS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S S
P
PS PS PS
U U U U
8) Other(Specify) S S S S
P PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PSS—_Provisionally Suitable
Recommendations/Comments:
Described by_ Title Date/-O-/-b
SITE DIAGRAM
DCHD(6.82)