182 Cottontail Ln J1 JA
DAVIE COUNTY HEALTH DEPARTMENT_ f
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Isgued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name =-Z2 -� ! /• x.- D to�,� r� N2 5885
Location Z-S" - ./f. y % s �',,r�l ,� r~ )/�7� ✓1 /,�>: .�=� lkx - 1--/ el
ter; r�"� ,��/.,�'.�`- ..�'�ps-• �� - ,- .j �� �,-�'' ��,� -,,�i- _'
i
Subdivision Name Lot No. _ Sec. or Block No.
Lot Size T! c' House if:f Mobile Home _ Business Speculation
No. Bedrooms _ No. Baths — Z No. in Family !9 _
Garbage Disposal YES ❑ NO p- Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ �� % `� ��
Type Water Supply __—
��3Xi� 2AV
*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 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 Installed by
V9
Y °f
Certificate of Completion ?J� 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 RECEIVED
Mocksville, NC 27028
1 . Application/Permit Requested By EU arA WCO fe-rry-jo '1
Mailing Address �. U I Ind VQ 7d U
Home Phone -/ / ff" M� Phone
Business W'��- �3q
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For : General Evaluation Q."S/Tank Installation
5. System to Serve: iuuse Mobile Home (] Business
L Industry Other 0 Unknown
6. If house, mobile home : Subdivision Sec. Lota
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms i/Basement/No Plumbing
Washing Machine 9-Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
S. Type of water supply : 0 Public 2rivate 0 Community
9. Property Dimensions 0- C.
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes �o
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify tnat the information provided is correct to tree
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
Date Signature
Directions to Property :
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Icl end o� Jl aaK�n vczkle� Rd.
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DCHD (10-89)
DAVIE COUNTY.HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name L or/n/�''� Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
® C9V d9 ft"
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS - �P9
U `Q
3) Soil Structure (12-36 in.) S S S
Clayey Soils
U U
4) Soil Depth (inches) S
U
5) Soil Drainage: Internal S S S
PS
U
External
P U
6) Restrictive Horizons
7) Available Space S, f S S
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification T Jp's- er
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title ' ��'� Date - 'y
SITE DIAGRAM
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UCHO(6-82)