P5208 Howardtown Rd • vj-.. _ ! .. . r r- - ^�•�+cVp -.r ...�.-„'r'"rllS�I�F'�tLlaq�`geTE��LY'•-'4+�Y1P��...-�. -. ..-V:.p": ..
i
DAVIE COUNTY•'HEALTH
IMPROVEMENTS PERMIT AND- CERTIFICATE OF COMPLETION
`NOTE: Iss;61ed in Compliance with G.S of-North Carolina..Chapter 1130`Article 13c
SNage Treatment'and Disposal,Rules (10 NCAC 10A`,.1934=`.1968)
Permit
, Number
Name c�� ems. :�,.e ���. DateISIS ISIS7y.". j�
Location �. '`
to
Subdivision Name Lot.No. Sec. or Block No.
Lot Size. •House Mobile Home _y Business __ Speculat6on
No. Bedrooms ='No. Bafhsjf No: in Family :-
Garbage Disposal. YES NO. [� Specifications for System:
Auto Dish Washer.' YES NO
'Auto Wash.MacHine,• YES .V
Type Water Supply ` > a, � __
*This permit Void;if sewage system described]below is not installed within'36 months from date of issue.
• -1•
Vit.. Improvements permit bye
"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 •
AA
S C)
,t Certificate of`Com letion 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. ,'
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone ��3 ✓ 2�S �
1. Permit Requested By �/f��v�+ 212.e— ��-� Business Phone
Address N
3. Property Owner if Different than Above .?0"-c- z C cry v Address — /_?1en--.-S v 1/5-
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 A-, Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes Nom
9. a) Property Dimensions !7_1ic
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.
E, — e"I&e'6 aa,"�Date fpyffer Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WIT,H[sALVL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: �✓ 1
/S S f0 J,awa V-C( �Ucv� rolJClr
os7 /eff
'Kofi
I
DCHD(6-82)
ti
:00
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name G {� \��� Date
Address �'Q Lot Size
FACTORS AR A 1 AREAS AREC3-) AREA 4
1) Topography/Landscape Positiony S
4 LES PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) 4ps:� A A PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils Ar PS
U U U
4) Soil Depth (inches) S
PS S �fh PS
U U U U
5) Soil Drainage: Internal S
PS S PS
U U U U
ExternalS
pS S PS
U U U
6) Restrictive Horizons
7) Available Space 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 S
U—UNSUITABLE S—SUITA PS—ProvisionallytSuitable
Recommendations/Comm ts:
Described by� - Title Date
SITE DIAGRAM
3 �014
DCHD(6.82)
Davie County NealtFr De artment
and .dome Aealtfr Deny
21 O HOSPITAL STREET/P.O. BOX 665
MOCKSVILLE, N.C. 27028
PHONE:(704)634.5985
May 13, 1988
Roger Lee Allen
Rt. 3, Box 449N
Yadkinville, NC 27055
Re: Site Evaluation
Howardtown Road
Dear Sir:
On May 13, 1988, as you requested a representative from this office
visited your site and found the soil provisionally suitable for the
installation of a ground absorption sewage system.
If you have any questions, please feel free to contact this office.
Sincerely, Q
Q164" k. `;L
Charles E. Little, R.S.
Environmental Health
CL/wd
Enclosure