5930 Hwy 801S4, DAVIE COUNTY HEALTH DEPARTMENT
1.
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
Slanitary Sewage Syste s _ Permit Number
Name
Date 1 a N2 5837
Location �� r1! t
I'? (�' � �'�_� t"`t.•. \= 1� :'S ��` � 1 � ��, � �.,.�� •d•-�..�., ',..rte
Subdivision Name 5�i3a k61AVOLAot No. Sec. or Block No.
Lot Size r:� :- t
House Mobile Home
_�✓ Business
Speculation
No. Bedrooms ��
No.
Baths No. in Family
f� —
Garbage Disposal
YES
❑ NO
Specifications for System:`
Auto Dish Washer
YES
❑ NO p�
c -
Auto Wash Machine
YES
p' NO ❑
"_�, x}
Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
1
m ��\ V\.
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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.
n a 11
Final Installation Diagram: System Installed by
F
Certificate of Completion Z�____ Date ZZZ IZ _
*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. 0. Box 665 D �AN ?
Mocksville, NC 27028
1. Application/Permit Requested By 11061- - l"2ed2S
Mailing Address ACI_ e % 1?30 100�iShclzle /VC, ..21-14-2,P
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: (,"General Evaluation 0 S/Tank Installation
S. System to Serve: 0 House Mobile Home 0 Business
Industryu Other 0 Unknown
6. If house, mobile home:
Subdivision
No. of People Dwelling Dimensions
Sec. Lot#
No. of Bedrooms - Basement/Plumbing
No. of Bathrooms, Basement/No Plumbing
0 Washing Machine (�' Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
8. Type of water supply: V Public* (9/private Q Community
9. Property Dimensions
10. Sewage Disposal Contractor
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? (] Yes . S -No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 'S
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from .this application.
Date Signature
(� r kAa"7)'� 0. -
DirE^t 'kon� to Property :
�r
DCHD (10-89)
Name—
Address
,5 A -v` 10
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARRA i\ AR4 91
Date 70
Lot Size
AMC) AC29:
6
I) Topography/ Landscape Position
�IF
c—PS
<3?t'
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
U
U
U
i) Soil Structure (12-36 in.)
Clayey Soils
PS
��
S
S
S
I) Soil Depth (inches)
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
�
.
.0
PS
U
U
U
External
�
S
�5
P
U
U
U
i) Restrictive Horizons
— --,
-
Available Space
PS
PS
S
PS
PS
U
U
U
U
i) Other (Specify)
S
PS
S
PS
S
PS
S
S
U
U
U
1) Site Classification
-S2
YLS
U—UNSUITABLE
Recommendations/Comments:
Described by
SITE DIAGRAM
DCHD (5-82)
S—SUITABLE PS—Provisionally Suitable
AqSon
Title Date �^