P4268 Gladstone Rd DAVIE 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 /1,T��1i�( � �t,�' i ,�� '�,i/ :?1, Date ii� ..`�, ��d.6 V
Location
r--
Subdivision Name Lot No. Seca or Block No.
Lot Size 1iouse Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family
—
Garbage Disposal YES Ej NO [X
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES V NO .Q
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
C1
Improvements permit by sf '
*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 /�'/427 4k,
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i
i
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.
RECEIVE;
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
'j�vl'Ct'Fa'sf/ Home Phone 4a s 7
1. Permit Requested By r Business Phone
2. Address -D X fewo 1 DLJ''
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. �•JC
5. System used to serve what type facility: House Mobile Home ✓ Business—
Industry—
usiness IndustryOther
b) Number of people -�
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions !j'404
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 2 showers washing machine
dishwasher sinks f
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes ✓No
9. a) Property Dimensions • 4140 ACQ CS
b) Land area designated to building site
c) Sewage Disposal Contractor l� o
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? O
What type?
This is to certify that the information is correct est of my knowledge. .
t
Date Owner gnature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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4.678 ACRE TRACT
To BE SOLD To
JOHN MOORE /
PER SURVEY of /
BY IV. HOWARD MAY 1375 1
DORRIS p E
EIP 5840 14' 34" �
644. 46'
AREA=1.087 ACRE E.Lq
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TO BE SOLD TO
-JOHN MOORE 6 3'92, �
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5 1.301 ACRE �
AREA= a�
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DEED BOOK B3, PAGE 706 RiW
I 60
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. 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 PositionS S
PS PS PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils P PS PS
U U U U
4) Soil Depth (inches) S S
p PS PS
U U U
5) Soil Drainage: Internal S S
p PS PS
U U U
External S S S
PS PS
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 a
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by ` ;T� Title Date
SITE DIAGRAM
DCHD(6-82)