P4886 Gladstone Rd y Jf `
Z s DAVIE COUNTY HEALTH DEPARTMENT L1
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIONJj
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.11968) Permit Number
Name /.,,1 k 0�7, r y '/J�'/, I Date
Location /'='�I ��' i• � 'r�' i; �� c- "� / _:,, ., �`r .
Subdivision Name Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home —!Z Business Speculation
No. Bedrooms No. Baths — _ No. in Family
Garbage Disposal YES ❑ NO 2" Specifications fpr System:
Auto Dish Washer YES T NO ❑
Auto Wash Machine YES NO .❑
Type Water Supply / __ ._3�Gt%��- j�/ It
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
L
Improvements permit by
*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 a '
v
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.
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
� ,�jrI ,N �� _Business Phone Z,� 3.2=74
1. Permit Requested By
2. Address —174 66/����L
3. Property Owner if Different than Above 4 -A P T'46- t4 t_�- .D 1):Z
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_Len�. usiness
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House DGs �Bath
Bed Roo Rooms—„�Den w/Closetrb) If Business, 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 2 urinals Q garbage disposal d
lavatory showers 1 washing machine 7
dishwasher sinks 7
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes—L--No-
9. a) Property DimensionsJm41+rz 46a�u- 7,&3 �2,oa aft _5iru-�y2ay
b) Land area designated to building site k4C.T
c) Sewage Disposal Contractor �ky
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)
. f
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 Position SS S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS
IJ U U U
5) Soil Drainage: Internal S S S S
PS PS PS
U U U
External S S S
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 =L� �/ Title ' Date 8
SITE DIAGRAM
p
DCHD(6-82)