128 Cedar Grove Church Rd DAVIE COUNTY HEALTH DEPARTMENT
y 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
NameDatefl li
Location -,, •�� w:. L. -y r� �\ E, �:- ,;;1\-
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 [g Specifications for System:
Auto Dish Washer - YES ❑ NO
Auto Wash Machine YES NO -❑ '
Type Water Supply
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
1
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 >
l
Certificate of Completion ' Date 44LI
'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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department ��OV
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
ome Phone '? 7Y Yf U 7
1. Permit Requested By c5iness Phone
2. Address &::Yo
3. Property Owner if Different than Above &AI Sold ID Q_e5jja. &� e,�V SMr7`h
Address
4. Permit To: a) Install-ZAlter Repair
b) Privy Convention al�Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions `7� ZaA4
Bed Rooms 3 Bath Rooms 1 :14 Den w/Closet s/
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--L,—/No
9. a) Property Dimensions t!E Q «214�j
b) Land area designated to building site I azLu42
c) Sewage Disposal Contractor ?
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 440-1•
What type?
This is to certify that the information is correct to the best of my knowledge.
Date J Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Aau A�tt� a4lt' A&14" 1CU4&L4- ;46- 40,11:'94�
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TH DEPARTMENT
DAVIE COUNTY HEAL
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name C, � ate
Address K`Q- Lot Size 46A\
FACTORS A 'T AR4L AREA 3 AREA 4
1) Topography/Landscape Position SS S
—(A PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, - S S S
Loamy, Clayey, (note 2:1 Clay) � PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils —A) PS PS
U U U
4) Soil Depth (inches) ,� S S
` S PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS
U U U U
External S S S
CR) PS PS
U U U
6) Restrictive Horizons
7) Available Space S S
PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE Ds—
rovisionaliy Suitable
Recommendations/Comments: ,v _�., o �_��ti�� >F- 4
Described by - Title Date
SITE DIAGRAM
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DCHD(6-82)