243 Gladstone Rd (2) ` DAVIE COUNTY HEALTH DEPARTMENT
-- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
_ f
*NOTE:`alssied 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 (/',+2•-/ flAticc1c e�_ Date j $ �hie 3 ir 47
Location Gn,I C j216117 Oyi A.n N17 r?t� 10-1 C, [`r f
Subdivision Name Lot No. - Sec. or Block No.
Lot Size /00 �� `f�' / House Mobile Home _ Business Speculation
No. Bedrooms S _ No. Baths No. in Family_
Garbage Disposal YES ❑ NO p `
Auto Dish Washer YES NO ❑ Specifications for System: /COG? <?u//oNk., l•
,' r !! ✓
Auto Wash Machine YES Z
NO .Q TUU X3 �� 5`1p
Type Water Supply 60UN7/ _ �i% L °n Jr. GJrJC�Ze If
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
(A t.
1�
F�CUNT
t
Improvements permit byfl�
"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
p i
1�2L~
� NSE
Certificate of Completion "1 ����� Date I V
*The signing of this certificate shall indicate that the system described bove 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
'atisfactorily for any given period of time.
Y' •
s ,^
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �r4 rrATlce�� Date ZG - g�
Address ��` 70c;'Z> Lot Size
•S�G�s�3v�! ./tlC 2��7
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position If§5 ® S S
PS PS PS PS
U U U U
2) Soil Textu 2-36 in.) Sandy, S S S S
Loam , Clayey, (note 2:1 Clay) (195 IM PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils 112i�!> ____® PS PS
U U U U
4) Soil Depth (inches) Q 0 S S
Pg PS PS PS
U U U U
5) Soil Drainage: Internal 01 - S S
PS PS PS PS
U U U U
External 0� ' --- ._ (5--> S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space 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
Recommendations/Comments:
Described by kff Title Date
SITE DIAGRAM
Q,
Z
0
AD
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Zo
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.
Home Phone t/O J7- 11y3
1. Permit Requested By R lw"VeDe,lz� Business Phone
2. Address D S U R ,0, M0
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair.
b) Privy Conventional ✓ Other Type
Ground Absorption ��
c) Sub-Division Sec. 7—Z 9 Lot No.A
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people -3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions X 9J
Bed Rooms—Bath Rooms a- Den w/Closet J
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 - urinals garbage disposal
lavatory a- showers 1Z washing machine Z
dishwasher sinks
8. a) Type water supply: Public Z Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions >C'b X .5-740'0
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? ND
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
loo/S - �.�.•�-�`y �°''f' .a-•-,�``,P �ia�-tom ��" .�-�' � �/a�-
DCHD(6-82)