246 Jack Booe Rd - '_ `✓1J � ,tea F_- - ,. .. _ x _ _ .. - ��O
} DAVIE COUNTY HEALTH DEPARTMENT
4 -IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter-130a,• :
Sanitary Sewage Syste . Permit- Number
�V2z5S
Name %� /" ? ate _ -,1/�1 / i N2 5952
Location „ 1Z • ,.��i 1 7tAU
Subdivision Name Lot No. Sec. or Block No.
Lot Size &C House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO 2--- Specifications for System: �
Auto Dish Washer YES NO E] e, tom- -e—,
Auto Wash,Machine YES NO ❑
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.
Yip
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 !/�/X
Certificate of i
l
Com eton �� N
r --1=f----- lJate
"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.
PPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
D�' ;.A
Davie County Health Department
�/ 1Q Environmental Health Section
P. 0. Box 665 DECEIVED APR 0 5 1990
Mockaville, NC 27028
R
1 . Application/Permit Requested By
Mailing Address t�� 3 aoX C. ri0
Home Phone
-sxca
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: lC) General Evaluation 011S/Tank Installation
S. System to Serve: House Mobile Home 0 Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People 3 Dwelling Dimensions
No. of Bedrooms a Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
Washing Machine J Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
S. Type of water supply: Public 0 Private 0 Community
9. Property Dimensions rw,nlp (y n�--
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes 0 No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
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.
_ -t- / 70 .
All
Uate Signature
Directions to Property :
1330
U Ise (�o J h5 4o ` cLd K 4\v-( ( 1Q (coo 4-o B oo e— ro d
go � �r�aa-e-(ro:�ye C f�i�-F r�ad�
� uS� -Mob. (e
�a�lc
ID d ��
� goX�s
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
//// SOIL/SITE EVALUATION
Name L".4Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ®
CPQ P
U U U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils S
U U U
4) Soil Depth (inches) �� S
Q.;7�'
U U U
5) Soil Drainage: Internal S SS S
U (tD -/-�U- — .
External S S
S S
U
6) Restrictive Horizons
7) Available Space --
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by � ,C,l Title �� Date '1 `
SITE DIAGRAM
DCHD(6-82)