P4829 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-.1//968)' Permit Number
Name c Date � g
Location 4
,!%'.i,.`-�"' 1/` ,• :,�'r--rrrst o,�•''�, ,�.�.�/ls'��7�! ,fir" �I
Subdivision Name. Lot No. Sec. or Block No.
Lot Size , House Mobile Home _ � Business Speculation
No. Bedrooms— N0. Baths.— _ No. in Family
'
Garbage Disposal. YES ,E] 'NO [2' i
Auto Dish'Washer YES NO Specifications for System: +' '
. . p..
Auto Wash Machine YES [ ] NO
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Type Water Supply _- _tom rYJ'a' �1 ii
*This•permit Void if sewage system described•below is not installed within 36 months from date of issue:
it
• Improvements permit,.kiy _ 6 ;
*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. ion day'of•:completion. Telephone umber: 704-634-5985. !
• ., it
Final Installation Diagram: S stem I talled by
70 /5 •��1r�C !,
Certificate of Completion �' Date '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. c
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P O. Box 665 RECEIVED MAY 2 9 11487
�C;'?�2
Mocksville, N.C. 27028
J CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested B � c Business Phone
2. Address rs i l
3. Property Owner if Different than Above c- f 5'
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 V 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 No
9. a) Property Dimensions
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.
1 8, --"11 qpd*z"Date U Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
G o . r n r i 5 h� o n CLct +o n�
p cL / h;e n go. +o Li-IYOR Pc o u�)1
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G" m c� G4 o nc.
DCHD(6-82) „
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Name /�C1�� � t Date 6
Address Lot Size 1pwe
FACTORS A EA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) S PS PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils S PS PS PS
U U
4) Soil Depth (inches) S S
PS PS PS
U U
5) Soil Drainage: Internal S S
Ig PS PS PS
U U
External S S
S PS PS
U U
6) Restrictive Horizons
7) Available Spaceis
S S
PS PS
U U U
8) Other (Specify) S S S
S PS PS PS
U U U
9) Site Classification t i
U—UNSUITABLE S—SUIT LE /–PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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DCHD(6-82)