750 Sheffield Rd (3) "> DAVIE COUNTY HEALTH DEPARTMENT ' 1 U b• (' '
i•e ., ;_ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION;,,' ', OD
' *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
sanitary Sewage Systems Permit Number
Name t��; F' � �� 11 �= �,, P 5S :_ ) c--•�\ Date _ ' NO 5835
Location 's
VA
Subdivision Name' ot No. Sec. or Block No.
Lot Size House Mobile Home _ Business _— Speculation
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No. Bedrooms No. Baths No. in Family - .
Garbage Disposal YES [2� NO EJ -
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO ❑ y 1 �; ^.vii'._ - �.`. {
Type Water Supply �:z.J , �,Z , - C f
*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.
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Improvements permit by
t y
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*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-G -5985.
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Final Installation Diagram: System Installed by , . kr W '^ e
1
Certificate of Completion Date
'The signing of this certificateshall 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
: f Davie County Health Department
Environmental Health Section �QN
P. 0. Box 665 RECEIVE
Mockaville, NC 27028
1 . Application/Permit Requested By
Mailing Address �7 �, ROA 113
Home Phone -92.2 5-3 5-J Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: C) General Evaluation S/Tank Installation
5. System to Serve: House ,' Mobile 'Home Business
Industryu Other 0 Unknown
6. . If house, mobile home: Subdivision Sec. Lot-
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No.. of Bathrooms . 41 Basement/No Plumbing
Washing Machine Dishwasher Garbage Dasposai
7. If business, industry, other: Specify type
No. of People Served No. of Sinks /
No. of Commodes No. of Urinals
No. of Lavatories oZ No. of Water Coolers
No. of Showers
8. Type of water supply : C Public ' Private Q Communi,r.y
9. Property, Dimensions d' x r0L 370
10 Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes. . No
If yes, what type?
+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.
Date Signature
Dire-^t 'k,on� to Property :
DCHD (10-89)
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s DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name \� - Date r ��
Address Cn 2 Lot Size
FACTORS AR90S ARE ARE 3 AREA
(;t)
1) Topography/Landscape Position
C:k�— S PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay)
U U U
3) Soil Structure (12-36 in.) —S
Clayey SoilsPS PS PS
U U U U ,
4) Soil Depth (inches) ,� S
PS PS � PS
U U U U
5) Soil Drainage: Internal SS E �
h
U U U U
External AP
U
U U
6) Restrictive Horizons
D G�
7) Available Space S S
PS S
U U U U
8) Other (Specify) S S S S
PS PS PS PS
9) Site Classification
U—UNSUITABLE SSPS—Provisionally Suitable
Recommendations/Comments:
Described by Title _ — Date - `I
SITE DIAGRAM
DCHD(6-82)