308 Lydia Ln (2) •e��"'�. �b•-�-'.;.a-!.�mow. � . . 4: .. .�,`� •�•: -f � 'r�i V. - ..
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
Name Qr� �����_ � P.!i��KR S? — Date " l ; %'" �Ci7 MID
G
f
Location V-) C,>'. 6 t5 �,� r�t�c a �l .`l �o
-•rte—�=. - - � �
Subdivision Name Lot No. Sec. or ock o.
Lot Size !., -House Mobile Home Business Speculation
No: Bedrooms No. Baths No. in Family
Garbage Disposal YES C] NO Specifications for System:
Auto.'Dish Washer YES ❑ NO
Auto Wash Machine YES. [�, NO -❑
Type:Water:Supply .
"'This permit Void}if sewag yst m del d b�elow�is not stalled within 36`months from date of issue.
6. � 60 ' x .3 'X izr�►!
.S d Tq IOU
'• Improvements permit by\ �--�
*Contact a representative of the Davie County Health Departm(eNumber:
for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30.P.M. on`day of completion. Telepho 704-634-5985.
Final Installation Diagram: 2y3tem In* I ed byOF
�' �� o� o-�•
L
f Certificate f 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 system will function
satisfactorily•for any given period of time:
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
o Home Phone
1. Permit Requested By \� Business Phone
2. Address x �CLr
3. Property Owner if Different than Above IL)
IH
Address
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 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 1 4 X no
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. ) Type water supply: Public Private Community
,,,,) Has the water supply sy a ben approved? Yes No
Property Dimensions
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 knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
c •
Directions to property: � q %O � o / j cd�N � jyJ I 7–p 421
( rto�
5
To L.0_ r�-- . I=a r')o �,
&f- _41 � �/0
1q ,� 7p
r \
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �? �2i�� �. � Date
Address Lot Size
FACTORS ARE 1 AREA AREA 3 AREA 4
1) Topography/Landscape Position S S S
do lT' PS PS
� U U
2) Soil Texture (12-36 in.) Sandy, _ S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils P PS PS
U U U U
4) Soil Depth (inches) S S S
p ' 4D PS PS
U U U
5) Soil Drainage: Internal S S S
(ZF PS PS
U U U
ExternalS S
p ' PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
p (IS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification S
U—UNSUITABLE S—SUITABLE PS— rovisionaliy Suitable
Recommendations/Comments: fir^
Described by �- Title Date
SITE DIAGRAM v�
/ bow
°b
o
DCHD(6-82)