170 Bailey Rd 5q,....r:.:...�+- a'sw-ry`'�yaa^.'ry w.;;...... :*,:3"''.,�ti fi.sr wc ,,as, to •<.S a:,. s.�^ v s Ar.s-..:V .T:. <. r ,. .< .r v-' . v :.,1:
DAVIE COUNTY HEALTH DEPARTMENT ~FB
1 IMPROVEMENTS PERMIT AND' CERTIFICATE OF COMPLETION °��
*NOTE:'Issuedin Compliance with G.S. of North .Carolina Chapter 130 Article 13c ��
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date N2 ;Ia
Location ► O S 1� \: 1 tJ �> QjK
<LZ!"'rrs
c
Subdivision Name Lot No. Sec. or Block No.
Lot Size ` - House, Mobile Home _�.� Business Speculation
No. Bedrooms4o''
N .,,Baths No. in Family
Garbage Disposal YES ❑ NO p-' Specifications=for System:
Auto Dish Washer YES p NO l 6 ,� o - XD =,Z b
Auto Wash Machine YES [ NO p ,�► t �)
Type Water Supply
*ghis permit Void if sewage system described below is not installed within 36 months from date of issue.
7
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 Insta'lle I by
a a o
d � �
Z
7 ° •i
Certificate of Cpmpletion ` Date l
*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P O. Box 665 RECEIVED MAR
Mocksville, N.C.27028 2 9
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone ) ���4_
1. Permit Requested By i01�/.� L7• .An%#V'i0 4D1 Business Phone '747.2-4000
2. Address �lv� iu. 47-4— iJU/L�-u N 7-702
3. Property Owner if Different than Above / ,6yA RJ
Address fit/ 9 RX 89 4Z)A Com. A., G '2 i 006
4. Permit To: a) Install ✓Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No
5. System used to serve what type facility: House Mobile Homed Business
Industry Other
b) Number of people
6. aj If house or mobile home, state size of home and number of rooms.
House Dimensions 'k7,0
Bed Rooms 2 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 2- urinals garbage disposal
lavatory 3 showers washing machine
dishwasher sinks 1
8. a) Type water supply: Public Private ✓ Community
b) Has the water supply system been approved? Yes No ►�
9. a) Property Dimensions ,/ mcnr- 22 /dcxe-c
b) Land area designated to building site p= 2 AcQ�t
c) Sewage Disposal Contractor
10. Do you antici to any additions or expansions of the facility this sewage system is intended to serve? �S
What type? 1d 7-6fRle /�oU
This is to certify that the information is correct to the best of my k wle ge.
37189 02�1
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: DVA��-g
01
CogN47- 1iLZI
204D �SS r--•-Z
._ . 1pam-w-P /Lir
:a
iClova.�cd ,,
OCHO(8-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 4�.LZ`�vt A'� Date 14
Address S � Lot Size
FACTORS AR 1 AREQ�, AR "3 AREA
1) Topography/Landscape PositionC S
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) —p Com—
. U U U
3) Soil Structure (12-36 in.)
Clayey Soils <ZEk <ZZE�
U U U U
4) Soil Depth (inches)
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S
U U U
External r
U U U U
6) Restrictive Horizons
7) Available Space
�S PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �- Title �� — Date
SITE DIAGRAM
------------------------
UCHD(6.82)