328 Riddle Circle ov
•5 - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION I I D UD
*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 /— /�.�/;� NO
5420
Location _
AL &4kdt=
Subdivision Name Lot No. Sec. or Block No.
Lot Size 7n House --�� Mobile Home _ _ Business Speculation
No. Bedrooms No. Baths --- No. in Family
Garbage Disposal YES NO p Specifications for System:
Auto Dish Washer YES NO fl
Auto Wash Machine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
BA:.1�
I �a
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 �N��
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Certificate of CompletionDate
*The signing of this certificate shall indicate that the system described above has been installed in cpmpliance 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.
f APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 . RECEIVED JAN ' 7 10
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
�r �5 Home PhorT/7 c775—-9ZY
1. Permit Re u, sted By i S Business Phone 5�A' M
2. Address VA IVC, C Za d
3. Property Owner if Different than Above.,-5AA! 'e.
Address
Ix
4. Permit To: a) Install Alter Repair
b) Privy Conventional r Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House -1 Mobile Home Business
Industry Other—
b)
ther b) Number of people
6. aj If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed RoomsBath 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,2, urinals garbage disposal
lavatory showers washing machine j
dishwasher sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply system�en approved? Yes �No
9. a) Property Dimensions
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? /0
What type?
This is to certify that the information is correct to the best of my knowledge.
/, S��bate - 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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DCHD(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 AL/
Address Lot Size 2,5�4 d-
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS' -PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey;(note 2:1 Clay) P (PSS PS PS
7j U U
3) Soil Structure (12-36 in.) S S
Clayey Soils P /Pte' PS PS
U U
4) Soil Depth (inches) S S
P (PSS PS PS
Z7 U U
5) Soil Drainage:Internal S S
P (P� PS PS
U U
External S S
PS PS PS
U U
6) Restrictive Horizons
7) Available SpaceS S
PS IS) 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—SUITABLE PS—
Recommendations/Comments:
Described by Title �� Date
SITE DIAGRAM
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DCHD(6-82)