127 Fairfield Rd (2) 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
bNAt is „y f.Gf=ScaN - Lt�J I+ 1'`i JZ_
Name �vj;4v�� r�r+.'r,•,� ., L,• ,., „� Date '- !fes' G ':; 291a
Location (�=-'1 j✓t2 �. L .n'"-r� A-T-
Subdivision
rSubdivision Name Lot No. Sec. or Block No.
Lot Size/,Z'),,\ ��� House Mobile Home — Business Speculation
r
No. Bedrooms - No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ //
Specifications for System:/00o �G���� tw•-�
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑ := '500 X j x /Z
*.1 S-TVNI L
Type Water Supply -D _ ;&,< ON Cz rjca.z Ti
`This permit Void if sewage system described ibelowi is not'installed within 36 months from date of issue.
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Improvements permit by %/`Y"G�
"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: � i System Installed by ReA, VI,4y
13
1'r.r� �i i z 3 kir C
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Certificate of Completioncribed- -\ _ �^^ Date `��
'The signing of this certificate shall indicate that the system desabove 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.
70 fc 3?-a33o
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
-a 3 �. Box 665
'70f., 633 Moc sville, N.C. 27028
f
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 1-;3 i" Aga l
1. Permit Requested B Business Phone ti,36- 9030
2. Address o
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓Alter Repair
b) Privy Conventional_tOther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people02" d-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath RoomsI Yz 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: Publico" _Private Community
b) Has the water supply system been approved? Yes >I-1 No
9. a) Property Dimensions 12-
b) Land area designated to building site s "' G '4�j
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? �4
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:
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DCHD(6-82)
• "R',«�z•;e.'.LrLAY%.^,�/ rrrtlfy thut �n •'_i�/ —' 198.1 I ,ul%w,ed the pier{reeIS "him fl on this plat,
that the property lines and location of all ,truc lures are accurately shorn hercon, that no structure located ytArtdlls,property
encroaches on any adjacent street or p.' I t'11'., And that no structure on adjacent properlyrnerut�c}ir,',�m 0�11r�rs
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PROPERTY OF
LOT NO. T _._MAP OF "'_." —_. ___._ _- _.__.— _.-- BLOCK NO.
PLAT BOOK _ PAGE COUNTY. N.C.
JE•C(JSAG�� Tw S'
bC:ALE 1 INCH �n FEET
60YTM64R P"OTO PRINT • PYPPLT ED _ '
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. 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 U
2) Soil Texture (12-36 in.) Sandy, S 7 S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS
� U U U
4) Soil Depth (inches) S S S
PS PS
U U U U
5) Soil Drainage: Internal S S
PS PS PS
U U U
External —JiM S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S. S S
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 S—Provisionally Suitab
Recommendations/Comments:
Described by Title c �lw" Date
SITE DIAGRAM
DCHD(8-82)