151 Justin Ct Lot 7.. "'. ::• .. .i':..,.,.« :,.....i.. ...„..V.n... .:,..: .. .. _.. _ a .... s. '- 0 -- .r ... -.w .. n ..._. Cyt
--� 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
2 / y n7
Name lC 4_t/1, c �+:��z c;.,,5 4' Date -?-- � �:�y Z)
Location —
Subdivision Name I-05 T1 N oo.►leo'- Lot No. 7 Sec. or Block No.
Lot Size 4 2G X— House Mobile Home _�'` Business Speculation
No. Bedrooms No. Baths Z- No. in Family Z '
Garbage Disposal YES ❑ NO ❑" Specifications for System: /Ooo
Auto Dish Washer YES NO ❑ ..
Auto Wash Machine YES NO.❑ 30 UX 3 12 e
Type Water Supply el UN T2? �- /s��� � Co N c :z r if
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
w, �–
50 !'f4,4-t (A S7 t
to
-Improvements permit bye--='
`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 5�1soN r'OizwA��'�
CAC-L- rN lSJ'
1 ,
( r f
Certificate of Completion�'"1'' Date
*The signing of this certificate 16hall 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
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address 3`X Lot Size (. AL_
`j,(,ocYsvrccc /VC
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
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
U U U U'
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U U
External S S S
dy 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 f 5
U—UNSUITABLE S—SUITABLE PS—P isionaliy Suitable
Recommendations/Comments:
Described by '�'� Title Date
SITE DIAGRAM
X
DCHD(6-82)
PPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone - '7717- 'Z
1. Permit Requested By M,77CIIA64' 1�,�TNY .SPR0b!SF Business Phone 21 y'722',?72
2. Address RT, 2 ROK19S�- l M00a1/241_,,_c N C: 27U2k (PR£SENni- 7(,6-g2VCAT0
3. Property Owner if Different than Above
AddressS'l7' Ttl 86 EVALG(� L60 - 4OT-97 7-0.CrZV Qak,T
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division JUS,EXV COCJRT.Sec. Lot No. — 11
5. System used to serve what type facility: House Mobile Home BusinessI&u� �`���£J
IndustryOther
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Room —Bath Rooms 2 Den w/Closet
Rooms 7
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 2 urinals Q garbage disposal
lavatory z showers washing machine
dishwasher 0 sinks
8. a) Type water supply: Publics Private Co munity CCdCrtY WhTEd�
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 496 f}G NS I$67**,,C/82"K 377y 1199
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 knowled e.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
FP'oM ThE .TJ7`6kS'KTT0W OF I y0 4- RWY, 90/c GO Z2 NI zL ES
7"OUJA-,,b Fi4 kM T.W6 TON, TA-K A � 7`SNr® OYAS7'=/V COIR 7" A 0
Ta T-M,5 CWD OF 7_/4F C:T CL E
-rv ��`
YAQ Kzv U� Y , t 1 s
7
11
9
DCHD(6-82)
FAC1jXN6 TO N