333 Joe Rd < DAVIE COUNTY HEALTH DEPARTMENT ; 3�
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
w''-*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
_Sanitary Sewage Systems - Permit Number
rNa / Fr i i �2 �ii. !�� / — Date N 2 5924
Location 6; �.� ����t'l' �(/„��� ,✓;/./ �-, ,�'�v %� -r%Yfr i ,!
Subdivision Name Lot No. c. ock No.
Lot Size House �� Mobile Home — Business Speculation
No. Bedrooms _ No. Baths No. in Family_Z _
Garbage Disposal YES ❑ NO p' Specifications for'System:
Auto Dish Washer YES 4 NO ❑ ✓�G,� � '
Auto Wash Machine YES [7j 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.
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 j
a
20 �/s a 6 o
Certificate of Completion / Date
r ,.
"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
V 1 � En ironmental Health Section
.� bC P. 0. Box 665 RuEN MAR 2 Q
Mocksville, NC 27028
V � U _
1 . Application/ rmit Requested By &Ci( yncu _
Mailing Address `'101 IJC)X
Home Phone q IQ- C) 01 ri t r) Business Phone -76LI -(.o 30--q 7 q, 12 eX4. )33
2. Name on Permit if Different than Above I
S. Property Owner if Different than Above � . )� C�
4. Application/Permit For: 0 General Evaluation S/Tank Installation
5. System to Serve: House U Mobile Home 0 Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lott
No. of People Dwelling Dimensions ,
No. of Bedrooms d Basement/Plumbing
No. of Bathrooms I 7 Basement/No Plumbing
Washing Machine r Dishwasher (3 Garbage Disposai
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(-Co.) 0 Private 0 Community
9. Property Dimensions A-er
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes 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.
- 1 I- ?)
Date S ' nature
Directions to Property : IL l L
ll' �asJ- aS7 N'rG, / j� �l l vr) r► �i7
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yr'1 i /e d o'co n r o ad on 1 e-�� T111 S-krY
97 DCHD (10-89)
., DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date :Zlz �
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S
P S P
U
2) Soil Texture (12-36 in.) Sandy, 4P
Loamy, Clayey, (note 2:1 Clay) - PS
3) Soil Structure (12-36 in.) �u
Clayey Soils
U U U U
4) Soil Depth (inches) � �F�
P (0
U U U U
5) Soil Drainage: Internal S
PS P
External 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� U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS_—Provisionally Suitable
Recommendations/Comments:
Described by ���� Title Date
SITE DIAGRAM
Yq
Y X
2
v�
UCHD(6-82)