2294 Angell Rd `� - _.�„ �'W�•�Zaa1:.�y61�- •'yiY^'��. x .ix -..e ;��e��,/�:� - �vwY��r . -. -. - ,. ,
DAVIE COUNTY HEALTH DEPARTMENT
� ,e IMPROVEMENTS PERMIT AND .CERTIFICATE OF COMPLETION
*`NOTE:. lssued`in Compliance,with G.S ,of•• North Carolina Chapter 130 Article 136- it
Sewage Treatment and Disposal Rules (10 NCAC.IOA .1934-,1968) Permit Number.
NameI
i;`'�� :�F�' /p, Date' ; j i2" 4 93 3
Location _ , i " .� ���
Subdivision Name• Lot No. - Sec: or Block No.
`I
Lot Size House Mobile Home Business Speculation
No.*Bedrooms No. Baths' —.No. in Family _ y
Garbage Disposal •YES 0 ' .NO I;e Specifications ,for System:.
Auto Dish Washer' YES NO. 'p
Auto Wash Machine : YES NO' T
Type Water Supply ..'
''This permit Void-if sewage system described below is not'installed'within 36 months from date of'lissue.
.- - - ....::•--.-•�- .. it
A
I
Improvements permit by
*Con#act a representative of the Davie County Health Department for final inspection of this system between--8:30-
9:30 AM. or 1:00-1:30 P.M. on day•of completion. Telephone Number: 704-634-5985. ;I
Final Installation-.Diagram. System Installed by
/00
l�
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 sysiem•will function '
satisfactorily for any given period'of time.
�j YC• alae. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
t V Environmental Health Section CC
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 9 g -3)19 9
1. Permit Requested By 17..Q -n,-, STANLEY Business Phone L3 Ll-2 S lam)- rMvA-sicp
2. Address IT R Iw t'x t o cjr S j i'/ 1:Q D
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-ZAlter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Bs
Industry Other
b) Number of people 3
6. a) If house o_r mobile home, state size of home and number of rooms.
House Dimensions—1 x'74 1!5
Bed Rooms—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 urinals garbage disposal
lavatory showers washing machine ✓
dishwasher sinks /�
8. a) Type water supply: Public;52_ T Private Community
b) Has the water supply system been approved? Yes 'f`No
9. a) Property Dimensions
sem- - —
b) Land area designated to building site
c) Sewage Disposal Contractor nA r kbo w
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? c"7
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:
10 1
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DCHD(6-62)
e
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ✓ Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, � S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S
pS PS PS PS
U U U
External S S S
PS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space 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 - ,
U—UNSUITABLE S—SUITABL PS—Provisionally Suitable
Recommendations/Comments: Z:_
Described by Title Date
SITE DIAGRAM
DCHD(6-62)