478 Jack Booe Rd TD`S �.- .. .
�. jilt DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
J *NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary ySewage Systems Permit Number
Nam ,. Z,Ze> 4,—L a-z) Date �1� N2 60 A
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size �_ tG House Mobile Home — Business _ Speculation
No. Bedrooms °� No. Baths 2 No. in Family f:L/Z,4
Garbage Disposal YES ❑ NO E�t' Specifications for System:
Auto Dish Washer YES NO ❑ / �/ 4Auto Wash Machine YES �j 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.
............ —
r-
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 / +` �.n2 �,
� J
Certificate of Completion Date 1
*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.
4 '
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ..,�'�{�/l�a�.�N Date �/ ` �✓��,/
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
(h�S' PS PS PS
jf U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) (PS' PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
�p PS PS PS
U U U
5) Soil Drainage: Internal S S S S
VSPS PS PS
U U U
External S, S S S
PS PS PS PS
U U U
6) Restrictive Horizons
7) Available SpacerrS) S S S
'OS 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—Provisio uitable
Recommendations/Comments:
Described by Title �' Date
SITE DIAGRAM
ti
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
V _ Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, NC 27028
1 . Application/Permit Requested Br� J.l
Mailing Address
Home Phone 7� ' ����� Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: 0 General Evaluation a-9/Tank Installation
5. System to Serve: [3 House 2-�obile Home 0 Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. .of Bedrooms C9 Basement/Plumbing
No. of Bathrooms _ Basement/No Plumbing
0 Washing Machine Fj 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
8. Type of water supply: 0 Public grPrivate 0 Community
9. Property Dimensions i9C
10. Sewage Disposal Contractor
11 . Do you anticipate additions/ex ansi.ons of the facility this system is
intended to serve? 0 Yes additions/expansions
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 applicat on.
Date Signature
Directions to Property :
DCHD (10-89)