P4282 Ridge Rd DAVIE COUNTY HEALTH DEPARTMENT
v , 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 (1 O NCAC 10A .1934-.1968) Permit Number
Name '1r % <%�`�r' Date ��� k �3i
Locations
off,
Subdivision Name Lot No. Sec. or Block No.
Lot Size 1 House r� Mobile Home _ Business Speculation
No. Bedrooms--1T-- No. Baths No. in Family _
Garbage Disposal YES ❑ NO p-- Specifications for Syst9m:
Auto Dish Washer YES NO ❑ "j
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.
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Improvements permit by ;� k',
*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 f C t�
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Certificate of Completion %x�l�r �� ��'-Da V-2
*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.
RECEIVE Mff? 1 7 1936
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 1747-;g
1. Permit Requested By_Tl1-bei V .,44adl 006_d"' Business Phone
2. Address IQf• �;Y '17 ,2&t lrM r,,r Y/G Z7ZD/
3. Property Owner if Different than Above 11/4 -),7oo-
Address �� t � "Ii -)7o `�w�. 3rr,
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: Housed 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 -:2V X �/V 19
Bed Rooms_Bath Rooms—2 _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 a urinals _ garbage disposal —
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private k"" Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions a 1 lA.,
b) Land area designated to building site
c) Sewage Disposal Contractor .1)144
61
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is correct
ptothe
/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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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Datefr
Address Lot Size--
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
( Ms PS PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U U
4) Soil Depth (inches) �j, S S
PS ( PSS PS PS
U U
5) Soil Drainage: Internal S S
P --&P PS PS
U U U
External S S
PS PS
U U
6) Restrictive Horizons
7) Available SpaceS 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
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by fa L/ Title Date
SITE DIAGRAM
a 4r:
DCHD(6-82)