133 John Peoples Ln.:r—. �...-,:�.1=aw..::-�r--.1..y-a:w+."+..�4i�i�*�.:a�✓,.a.1-....++.-.ivJ-"�Svrv.+-..v�..,.�,,.v,,,.a-�--�«-W..tir'�«,.:: t---`a+..r �.,.�=4 �.,+^.+.....�--. �. ...�. -_.. ....�.. -.. ,
DAVIE COUNTY HEALTH DEPARTMENT
• _ ' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued in Compliance with G S of North Carolina Chapter 130 Article 13c
C
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name l r , ?rig/ t�� s�..E/� '/i -Date j X % L `t �. Q 1
Locacon r
Subdivision Name Lot No. Sec. or Block No.
Lot SizeHouse Mobile Homed Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO p/ Specifications for System:
Auto Dish Washer YES �NO ❑ %),/� ��,
Auto Wash Machine YES NO ❑ ��v, �
Type Water Supply
AV
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
1�---
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 • Y
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.
r
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.
DAVIE COUNTY HEALTH DEPARTMENT
_. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ' '1 '', �, ! . - ,1 `Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size %/ House Mobile Home Business
No. Bedrooms No. Baths _ _ No. in Family Z
Speculation
Garbage Disposal YES iLj NO U- Specifications for System:
Auto Dish Washer YES [ NO 'p
Auto Wash Machine YES p NO ❑%`' :' ` '
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
y
Improvements permit by
`Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:30
: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
T 3 �
cJ '
1'
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.
G ` .
• s
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMO,,
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
i
1. Permit Requested
2. Address Pf-
3. Property Owner if Different than Above 614 M - w
Address ;�?*-
4. Permit To: a) Install l Alter Repair
b) Privy Conventional (Other Type
Ground Absorption
Home Phone
Business Phone G Q 9- 3 9
'7 cz- c l
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home 1000` Business
Industry Other
b) Number of people q
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions b -
Bed Rooms a 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 o9, urinals
lavatory
showers
garbage disposal
washing machine
dishwasher sinks
8. a) Type water supply: Public Private **'- Community'`
b) Has the water supply system been approved? Yes No–==' -
9.
o /9. a) Property Dimensions
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 to certify that the information is correct to the best of my knowledge.
a-7 z_:11 ;g� �`����"
Date wner Si ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6.82)
w
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FAnT[1RS ARFA 1 AREA 2 AREA 3 ARFA 4
1) Topography/ Landscape Position
9)
S
S
S
PS
PS
PS
�--�j
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
U
f) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
I) Soil Depth (inches)
S
S
S
g
(!S7)
PS
PS
PS
U
U
U
�) Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
1) Restrictive Horizons
Available Space
S
S.
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
OZZDescribed by Title Date
SITE DIAGRAM
0
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JG�
DCHD (6-82)