184 Serenity Dr (2) DAVIE COUNTY HEALTH DEPARTMENT
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION C)
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a ,- A
Sanitary Sewage Systems ,.z tt Permit Number
Name �� �_., 4 �� \; Date i ` ( ^L lIJ NO 5810
Location
Subdivision Name Lot No. Sec. or Block No
�'��
Lot Size House Mobile Home_ Business Speculation
No. Bedrooms "'Y No. Baths No. in Family
Garbage Disposal YES ❑ NO 2' Specifications for System:
Auto Dish Washer YES ❑ NO []/
Auto Wash Machine YES ❑ NO
.Type Water Supply
*This permit Void if sewage system described below is not installed within 5 years from date of issuer
This permit is subject to revocation if site plans or the intended use change.
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 ���� -�
u
Certificate of Completion 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.
r
.�� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section 1 �
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN
/ISSUED.
Home Phone 7 92 S�yB
1. Permit Requested By ;Q d• ,� Business Phone
2. Address G ems_-,�, 76-?S)
3. Property Owner if Different than Above . 9e1
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
Industry Other
b) Number of people /�- Z
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions
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 urinals garbage disposal
lavatoryy showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private `� Community
b) Has the water supply system been approved? Yes —No
9. a) Property Dimensions Zy ?
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?
What type?
This is to certify that the information is correct to the best of my knowledge.
Zu
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�- /)4
1AL
*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.
'I Effective October 1, 1989.
DCHD(6.82)
i`` DAVIE COUNTY.HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name \�\� 'z �-� Date
Address Lot Size
FACTORS ARCA 1 ARB AREA 3 AREA 4
1) Topography/Landscape Position S S
PS PS
�j U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS PS
U U
4) Soil Depth (inches) S S
pS PS PS PS
U U
5) Soil Drainage: Internal S S
'pg PS PS PS
U U U
External - S S
pg PS PS PS
U U
6) Restrictive Horizons
7) Available Space - S S
PS PS PS PS
U U
8) Other (Specify) S S S S
PS S PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date `� v
SITE DIAGRAM
DCHD(6.82)