P3203 Rainbow 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.
Permit Number
Name fir �2� '�. ��rti Date Z- 21 -23 � � �}
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Location ?cAla-0 P„A,' _ 1r �r `t'_.n•, i?�Q - .;
Subdivision Name Lot No. - Sec. or Block No.
Lot Size cy �` i r, House Mobile Home — Business Speculation
No. Bedrooms No. Baths No. in Family
-
Garbage Disposal YES ❑ NO
Specifications for System:l�- 0,'P•ick•�K-
Auto Dish Washer YES 2''NO Eycl
Auto Wash Machine YES [j]'"INO ❑
Type Water Supply _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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 byi1
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Certificate of Completion -� � !�11� 0 Date r J
*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
p SOIL/SITE EVALUATION
Name .� �i� l �� 2`2 Date Z " 2' 7
Address ��� 3 h'y� ��-� Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S SS S
Clayey Soils ® dD PS PS
U U U U
4) Soil Depth (inches) S S S S
+` ® g 1" PS PS
�3 U 3 U U
5) Soil Drainage: Internal S S S
(h PS PS
U U U
External ® S S
PS PS
U U U U
6) Restrictive Horizons
3
7) Available Space 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 S S
U—UNSUITABLE S—SUITABLE / PS—Provisionally Suitable
Recommendations/Comments: a ('d-9le
Described by •rn � Title&"- Date 2 74-s
SITE DIAGRAM
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311
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« APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT tiv
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 q 7a - �o n O
1. Permit Re uestgd By Business Phone 72 7-loses y—
2. Address V - auevo
3. Property Owner if Different than Above
Address
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: House,..Mobile Home Business
IndustryOther
b) Number of people a
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �)R - r1 C)
Bed Rooms Bath Rooms_Den w/Closet_fk2O_
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 2 urinals garbage disposal
lavatory I 'r4 showers) washing machine
dishwasher I sinks
8. a) Type water supply: Public.—Private community—
b) Has the water supply system been approved? Yes. No
9. a) Property Dimensions Aq1 - )1n
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? tuD
What type?
This is to certify that the information is correct to the best of my knowledge.
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Date Owner Signa ure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AN I CAL LAWS
Allow 5 days for processing
Directions to property:
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