811 Ratledge Rd DAVIE COUNTY HEALTH DEPARTMENT
A4 '~ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NTE: 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 / . : i%`i �' ,,:" ,r/ �.'r - / Date 03
Location Z
Subdivision Name Lo T� Sec. or Block No.
Lot Size House Mobile Home — Business Speculation
No. Bedrooms No. Baths '`'� No. in Family —
Garbage Disposal YES ❑ NO,Ey Specifications for System:
Auto Dish Washer YES 0 NO ❑
Auto Wash Machine YES j NO ❑ C' �' ' `�
Type Water Supply r�+/', ;� _ `4
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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1 I provements permit by
"Contact a representative of the Davie County Heal tt�� epartment for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. e epho%e Number: 704-634-5985.
Final Installation Diagram: System Installed by
117
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oor
Certificate of Completion �< /C Date
'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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone -119.2-
1.
902-
1. Permit Requested By M )��V Business Phone
2. Address o s
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 Se sC Lot No.
5. System used to serve what type facility: House ''VV Mobile Home Business
Industry Other
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 3tx3 p
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 :I" urinals garbage disposal
lavatory 2 showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private V Communit
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 6 AC'r<'!5
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions facility this sewage system is intended to serve?
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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0/1`r�" rocLJ 0hr � C Lo�� ✓ e-j Cross
_ s '50
A �i-ibr� 04Ga le, c'OrasS �'�-
row o�, 0 10
DCHD(6-82)
r. DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name pore4��ell( Date
T
Address Lot Size t��)�(41
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U
3) Soil Structure (12-36 in.) S S S
Clayey SoilsPSS, PS PS
(SJ1 U U
4) Soil Depth (inches) S S S
PS PS PS
qu U U U
5) Soil Drainage: Internal S S S
PS PS
U U U
External S S
(PSJ PS PS
U U U
6) Restrictive Horizons A9
7) Available Space S S
PS 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 i S.
U—UNSUITABLE S—SUITABLE PS-Provisionally Suitable
Recommendations/Comments:
Described by / Title
SITE DIAGRAM 1117
G
DCHD(8-82)