P3131 Indian Hills DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name.5-1 Date
--c•a¢n
Location 7'01,j,
Subdivision/Name Lot No. _ Sec. or Block No.
Lot Size t `'� ` House �'� Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family &
Garbage Disposal YES ❑ NO 2---
Specifications for System: �, - �' �(�
Auto Dish Washer YES [p NO ❑ i �J
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.
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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.
Final Installation Diagram: System Installed by/Ag [,DENA7;,
Certificate of Completion - `r4 `J Date
'The signing of this certificate shall indicate that the system describe 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ERfa F., /OOTTS SAW Date �- 23 �� Z'
Address AT.- 'y 0"X $ Lot Size /6 /4cn�s
Abv, c--- AJc 270o(.
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ��S�., S S S
P,5► PS PS PS
U U U
2) Soil Tex 2-36 in.) Sandy, }� `� S S S S
Loam Cl yey (note 2:1 Clay) c4q-$- PS PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS 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 S,
PS PS PS PS
U U U U
External 0 S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
i
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 �PA-:S Title S'�'TAF-,rA►-/ Date
SITE DIAGRAM
6.
DCHD(6-82) -
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT . ti3
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone -/` 'f �L'mg
1. Permit Re ,used By Business Phone
7
2. Address '" 4b
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-DivisionSec. Lot No.
5. System used to serve what type facility: House ome Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions In o �
Ny3
Bed Rooms g 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 Y 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 u
b) Land area designated to building site L
c) Sewage Disposal Contractor 'Se t' 1'j h �' +!�? 7 •��i'
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Ll —
What type?
This is to certify that the information is correct to the best of my knowledge.
r
Date Owner-Srgnature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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too.
.Tf,jvJ T /SGS
DCHD(6-82)