234 Riddle Circle j� .. DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:I sued in.Compliance With Article 11 of G.S.Chapter 130a �3
anitaTy Sewage Systems ' Permit Number
Name tlM A//�;,,� ����— Date
116861
Location � --„ �" rr� – �'"7�(�i�,� -
'`.S��°°!��Cfi:l� ' � � • /t/(r ice- /.i_(
Subdivision Name Lot No. Sec. or Block No.
Lot Size _ House Mobile Home 1--' Business _ Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO
T Auto Dish Washer YES [:] NO Specifications for System:
Auto Wash Machine YES ❑ NO
Type Water Supply (d __ C�Od X 3Xjc)
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
Improvements permit by Aa
*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 L11–
1�
Certificate of Completion a-- 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. Sox 665 Q�
ff J Q Mockaville, NC -27028
1 . Application/Permit equested By 4 / ,4Ma C1- /V OGL'C rl/S
Mailing Address f � "8 x A&'1:14 06
Home Phone ��� S�� Business Phone 6.T4Z`3S6
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit. For: 0 General Evaluation 2f,,,S/Tank Installation
5. System to- Serve: House �Mobile Home (] Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions f,,/z x b
No. of Bedrooms Basement/Plumbing
No. of Bathrooms Basement/No Plumbing
0 Washing Machine r Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: �, Public 0 Private a Community
9. Property Dimensions / C[.C"�__
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? &Yes No / ,/ ?
If yes, what type? _ &' L4) 6�t
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
Signature
Directions to Property :
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name D��h-� Date ;1
Address Lot Size /,I-
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position 3pGSA
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) S —or --afs
U U U U
3) Soil Structure (12-36 in.) S �S .� � �
Clayey Soils
U U U
4) Soil Depth (inches) S S S S
U U U
5) Soil Drainage: Internal � � � �,
U U U U
External S S
S �� P
U U
6) Restrictive Horizons
7) Available Space
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 , ,
U—UNSUITABLE S—SUITABLES—Provisionally Suitable
Recommendations/Comments:
Described by ,,�� Title �, � Date
SITE DIAGRAM
DCHD(6-82)