187 Jamestowne Dr DAVIE COUNTY HEALTH DEPARTMENT % U o
-�- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
" Sanitary Sewage Systems Permit Number
Name 5�7 - . 7 �, Date �� >/7 N� J
Location `
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Subdivision Name Lot No. Sec. or Block No.
Lot Size 1461 House Mobile Home _ _ Business Speculation
No. Bedrooms No. Baths –,*2 No. in Family
Garbage Disposal YES ❑ NO 0- Specifications for System:
Auto Dish Washer YES } NO ❑ y
Auto Wash Machine YES [fj NO E] C1��-rte
/r/rt.� -�/moo X-�',�'.�.� • �-e��y
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 revoctidln,if site plans or the intended use change.
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Improvements permit by i
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*Contact a representative of the D ie County Heth Department r fib nal inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on ay of complet' n. Telephone umber: 1)4-634-5985.
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Final Installation Diagram: a Z � stem Instal d by sx
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Certificate of Completion Date
'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
V Davie County Health Department ISM` Environmental Health Section E�E��ED AN 1 2
10 P. O. Box 665 R
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
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Home hone
1. Permit Requested By Business Phone 7 _Ce 1)- 3 10
2. Address &C 0_ t1j . 0, B
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy��Conven'tional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home ✓Business
IndustryOther
b) Number of people s
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions 14 X I 2�
Bed Rooms_Bath Rooms L v Too r►, n
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 1=2 urinals garbage disposal n-
lavatory A showers washing machine
dishwasher sinks 3
8. a) Type water supply: Public • Private ✓ Community
b) Has the water supply system been approved? Yes No W e A l `to b e d uS.
9. a) Property Dimensions b n ma 4
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? _
What type?
This is tocertifythat the information is correct to the best of my knowledge.
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Date �— Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: -
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1713 � '4tPv
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DCHD(6-82)
4
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Heath Section
P. O. Box 665
Mocksville, N.C. 27028
1 SOIL/SITE EVALUATION
Name �" Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) 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 PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S 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
s
Recommendations/Comments:
Described by l7 Q ZZ Title n Date I
SITE DIAGRAM
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DCHD(6.82)