P4939 Pine Ridge Rd Wi.-.�'iJ:'4..M :.l l..l•:li•+-ti..�sr ..:+C�yr.*•-i.x .:.�.Jw::;v:h;i:=+t..:iyji. ,;:�;yu .r"...�la'i��Yw��.fi,sw+`h-i`.'�,C••�,,,,, .ni:ti"'v'ati'• is 6,`,'*".`_ �P,..- i w..� s{.., .. .,
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
Date
Name ' '� s',' �,J.,.r��l;/, " >ij, !�f'I
,a
M-,4 /
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size " House Mobile Home �/� Business Speculation
No. Bedrooms `� No. Baths e No. in Family a
Garbage Disposal YES E] NO 2-- Specifications for System:
Auto Dish Washer YES 4 NO
Auto Wash Machine YES NO
1
Type Water Supply __—
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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.
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Final Installation Diagram: System Install�d by �r ^--� ���� %� ✓T `/
G sl
L
Certificate of Completion _�G`{ � Date
le signing of this certificate shall indicate that the system described above has been installed in compliance with
standards set forth in the above regulation, but shall in NO way be taken as a guarantee that the system will function
sfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEME S PERMIT 1�
/r/
Davie County Health DepartmentV,
Environmental Health Section '
P. O. Box 665
Mocksville, N.C. 27028 R
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMERMIT HAS BEEN ISSUED.
�./ Home Phone ��/ �--���
1. Permit Req ested B Business Phone
2. Address n
3. Property O er if Diffe ent than Abov
Address
4. Permit To: a) Install Alte Repair
b) Privy Conventional Other Type—
Ground
ype Ground Absorption
c) Sub-Division Sec. Lot Nom—
5. System used to serve what type facility: House Mobile Home Business ..
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions -
Bed Rooms —3 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. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions_-Z` 6 al-AA 4�32
b) Land area designated to buildin site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansi ns of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct to the best f my knowledge. /
i4 11/
Date Owner Signa ure
OWNER IS SO 4:��LY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
/' Allow 5 days for processing
Directions to property-
ID
rope y:ID(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. 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
P5) PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
Lw U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
0 U U U
External S S S
pS PS PS PS
U U U
6) Restrictive Horizonsl
7) Available Space S S S
is PS PS PS
U U U U
8) Other (Specify) S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUIBEA/ S—SUITABLE PS—Provisionally Suitabl�
Recommendations/Comments: 'S
Described by !� Title Date
SITE DIAGRAM
V I�
DCHD(6.82)