1216 Davie Academy Rd h L �` DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE}issued in Compliance With Article 11 of G.S.Chapter 130a '
Sanitary Sewage Systems Permit Number
Name -JI)k . /���. �, ,,i s'/ r,n,'�'�= i, Date N2 5820
LocationT ;771
�, 3'1'/r �.r !`•�.. c /'.-;!� /-1r'.?�f% — 1.f`� y ,r . ��x`rc:
Subdivision Name Lot No. Sec. or Block No.
Lot Size House ! Mobile Home _ Business _— Speculation
No. Bedrooms No. Baths �,-f No. in Family
Garbage Disposal YES ❑ NO ❑' Specifications for System:
Auto Dish Washer YES NO ❑ ,/�`' , "�
Auto Wash Machine YES 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 byC' 7�
*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 -n, -;7r,
u s e
r. 1
21
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ted: L .,a
a3..L..
Certificate of Completion �. -�__ �� Date 1-
"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.
4rGo C
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
0 - �J / Davie County Health Department
Environmental Health Section
P. O. Box 665 RECEIVED ..,*.,
Mocksville, N.C. 27028 i G IVED ..,*., 1990
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
,/P Home Phone Z.V-S34Z
1. Permit Requested By _`(oad Ada �er,J �E.J Business Phone (-E-34-2-9'
2. Address PC 6ck Z ( Grrnr}e 0LArre, Ac ?Vo- Z
3. Property.Owner if Different than Above Ck ealda-A( Qa
Address I?{• I go)c 2Ijl_A M4cbV�I(e1 r4C '2702'-r
4. Permit To: a) Install Alter Repair
b) Privy Conventional ✓ Other Type
Ground Absorption
c) Sub-Division Sec. Lot No. S/T�
5. System used to serve what type facility: Housed Mobile Home Business
IndustryOther
b) Number of people 3
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions 71 X 5 Z
Bed Rooms 4- 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 3 urinals garbage disposal
lavatory showers 3 washing machine
dishwasher 1 sinks"
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site 2 OF, QCAf-
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Alo
What type?
w
This is to certify that the information is correct he 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:
.fav; e AcoJeMN eoctd -* 1 (43
I n-�2 rSe.0�.O ti �r• �C n r j'S e0a t 64), C')"I -C)Mo e ACO e' Codd yo Cc M"12 O►
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g/f T P AD x6lI TYX Gfll✓ �Iod� �Def�ZI�� . d rt G`.
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*NOTE: Improvements Permits shall be valid for a period of 5•
years from date issued. Improvements Permits are subject
j to revocation, if site plans or the intended use change.
Effective October 1, 1989. f
DCHD(6-82)
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,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��� Date
Address Lot Size Z46,
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionQ C
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S --� S
Loamy, Clayey, (note 2:1 Clay) % S A) ��J
U lJ
3) Soil Structure (12-36 in.) S S S
Clayey Soils
U U
4) Soil Depth (inches) VS
U U
5) Soil Drainage: Internal S S
Ap PS q &P
U U U
External �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: c�
Described by Title Date 1 vzy m
SITE DIAGRAM
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DCHD(5.82)
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1 ry® 1( 3. 91
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Q;• m
HICKORY
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RANDALL CAVE
p a°' P�a 62.59 ACRE`
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h� 1164. 72 - -
`� S OG• 3 B" 10' W
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
�.
Davie County Health Department
Environmental Health Section
P. 0. Box 665 RECEIVE®
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone Z 7 I �'�4 -2
1. Permit Requested By rl,! U A;0, f,f10,,/ (} E nl _ Business Phone
2. Address t' ) 607°I c=r' nide .err:, rJ'' s'c"►Z
3. Property Owner if Different than Above &Ckh a ( caye, _
Address Et I you 21j"1,A M.ocksv;(lc, n(C '27028 y
4. Permit To: a) Install \ Alter Repair
b) Privy Conventional v Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.-
5.
o.5. System used to serve what type facility: House\ Mobile Home Business
Industry Other
b) Number of people
6. a)If house or mobile home, state size of home and number of rooms.
House Dimensions -�
Bed Rooms `- Bath Rooms l— 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 urinals L) garbage disposal
lavatory 5' showers washing machine {
dishwasher I sinks I
8. a) Type water supply: Public Private x Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 'IL" cr 0 K e S
b) Land area designated to building site 260=12LaCKeS
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? AIC*
What type?
This is to certify that the information is correct he 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:
.taw e Acad e k&4 114 3
load , I?4y load amu'e �ead e u-y COad %io C rte;I e 06-
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' *NOTE: Improvements Permits shall be valid for a period of 5
I years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
fl Effective October 1, 19899
DCMD(6.62)