594-596 Gordon Dr ,= :> DAVIE COUNTY, HEALTH DEPARTMENT
IMPROVEMENTS :PERMIT AND CERTIFICATE OF COMPLETION.,
*NATE: -Issued in Compliance with G.S.:of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal RulesT(10 NCAC 10A .1934-1968) Permit Number.
Name �� �� ~s ..L,� : ; � \ \ Date - �r�" �' 5171
Location � c .
II L, 1� �.'1 r=rt`�—•�i'�'�'V iR..s.A1 � e �'i�,h..i T.xS.. F-"!�, � _�+.-�
Subdivision Name Lot No. Sec. or Block No.
Lot ;;Size ' House Mobile Home _ Business' Speculation
No Bedrooms_ No. Baths.' No. in Family—�—
Garbage Disposal, YES '❑ NO
l Specifications for System:
Auto Dish Washer '--' YES ❑f NO-,
Auto Wash Machine YES p NO -❑.
E U'�
X 31
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
• it �... .71All
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II ,
I� Improvements permit by�.. 7t
*Contact a representative of the Davie County Health Department for.final inspection of this system .between 8:30-
9:3,0 A;M. or 1:00-1:30 P.M. on day of-completion. Telephone Number:704-634-5985.
!f
Final Installation Diagram: , - System Installed by.
i Certificate of Completion Date w
*The; signing of this certificate shallindicate*that-the system -described abovehasbeen installed in compliance-with.
thelstandards 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
'► t 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.
L
Home�sPhone
1. Permit Requested By �— -ea$ess Phone 2 Z�'j� 9-!
2. Address a
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 Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 0A "E;D
Bed Rooms -2-' 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 sys'e'/`m been approved? Yes No
9. a) Property Dimensions %� a�w�
b) Land area designated to building site %. ac/"'"(Z'_
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 -ft(s-Quan_r Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
�,�
Address � Lot Sizes
FACTORS ARE 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, y�—, S S S
Loamy, Clayey, (note 2:1 Clay) 9 PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS
U U U
5) Soil Drainage: Internal 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
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLES— PS—Pr visionally Suitable
Recommendations/Comments:
Described by �- TitleDate
SITE DIAGRAM
UCHD(6-82)