117 Garden Ln DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Aote: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name /f' ,' - Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size %'{ House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES p NO p- Specifications for System: s
Auto Dish Washer YES p NO p
Auto Wash Machine YES [] NO p
Type Water Supply
✓fir. �
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
r
r
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-lnstalled.by "' '����" °7 � � !'%fir �✓
heCertificate of Completion -r`-% ! 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name R,41yD/41,1- Date
Addressi Lot Size aC�ua+,v
/ylo41/1(,1/lc /JC Z 70 2�'
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
(2p PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, Syam, S S
Loamy, Clayey, (note 2:1 Clay) S (t) PS PS
<j U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils q <�R> PS PS
U U U
4) Soil Depth (inches) G " S S S S
PS PS
U U
5) Soil Drainage: Internal S S S S
PS PS
U U U
External S S S S
�S> PS PS
U U U
6) Restrictive Horizons
7) Available Space S S
S 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—Provisional iy Suitable
Recommendations/Comments: 0JV
7�7�•��Q
Described by c�-��� Title Date'' c
SITE DIAGRAM
DCHD(6-82)
4�
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT big
Davie County Health Department c
Environmental Health Section cV�
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone fly"S7lo�
1. Permit Requested By F/ 4%q4� C, AlAGLSER Business Phone
2. Address JRoo1T- 2 'BOX .4,41A 1720C1tSV/1-1-E4&,,C, a 70 -.)-F?'
3. Property Owner if Different than Above ( LA V
Address R2 j7-X_ ::? 201X 1W APCksv/LGA
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: HouseJe�=IVlobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of.rooms.
House Dimensions 700x, -r
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 a- urinals garbage disposal
lavatory. showers washing machine
dishwasher sinks
8. a) Type water supply: Public PrivateL---'- Community/
b) Has the water supply system been approved? Yes No�G
9. a) Property Dimensions p&o)(, 2 ct rc�
b) Land area designated to building site
c) Sewage Disposal Contractor .gennj ro s
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 1
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:
DCHD(6-82)