175 Blackwelder Rd 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 ?cf7C "JI, 02e- Date3 3'417
Location N Ti//Iv LfF7
Subdivision Name Lot No. Sec. or Block No.
Lot Size / • House ✓� Mobile Home — Business -- Speculation
No. Bedrooms 3 No. Baths Z A— No. in Family Z —
Garbage Disposal YES p NO p_*� �-
Specifications for System:/000 �-
Auto Dish Washer YESNO .0 (�
Auto Wash Machine YES j NO ,0 30tJ�x 3�
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
CALL EkAL-rfI
Z�
-- –`` 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 �Pp Waic" -
SltLrt 7 u,4 N
J
Certificate of Completion -==�^we,'.1 Date 1-7
*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
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name c//44p-r Dn �mc�,5ez�c2 Date 2 7 -
Address /`'T &-K J-0 Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position <:15 f S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) li%5 kps C-1-57 PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils <f5g> Z�v PS
U U U U
4) Soil Depth (inches) r(15 S S
PS PS (M PS
U U U U
5) Soil Drainage: Internal _® ____ --mS
S PS PS PS
U U U U
External � a) (!:q� S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space ® S
PS PS PS PS
U U U U
8) Other (Specify) S
PS PS PS PS
U U U U
9) Site Classification PS
U—UNSUITABLE S—SUITABLE S—Provisionally Suitable
Recommendations/Comments:
Described by .s Title Date 2 7-d�
SITE DIAGRAM
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
// Home Phone '5/2a �G �y
1. Permit Requested B L1,4'a1c�F' fie% Business Phone
2. Address o x &Oo Aro,//F iu. e. a a
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional her Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House-kf:'--Mobile Home Business
IndustryOther
b) Number of people �'�o 6a�
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions d .7
Bed Rooms 3 Bath RoomsQ��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
lavatorya showers washing machine
dishwasher sinks
-� c%e c/ e.4e die a Co4-w1y
8. a) Type water supply: Public Private Community J
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site Qes
c) Sewage Disposal Contractor 'P'4'eA)'E;4 c4c
10. Do you anticipate any additions or expansions of the fa ity this sewage system is intended to serve? Ny
What type?
This is to certify that the information is correct to the best of my knowledge.
Ax
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days jor processing
Directions to property: MD u�, AS 40 4e
180 /4
Ale �e 7`r p'�' e� Vollirl
Z61Ae el Gee K�eQ TY. "QT a"' � 7( 1��� i-T.
re A.) 0/ �eQy
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