184 Serenity Dr VV l M/ozj
DAVIE COUNTY HEALTH DEPARTMENT
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 (10 NCAC 10A .1934-.1968) Permit Number
Name M1 t flA4 Gn r rl r�- /L` Dated f -��� `r , Ili
Location ��y W lei rrr. i? �LGf !Z-a�► � r2ou;> Siva. Ic ��r j>ile t"
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Subdivision Name Lot No. Sec. or Block No.
Lot Size 2'0 x y3 House ` Mobile Home _ Business Speculation
No. Bedrooms 41 No. Baths 4V No. in Family _
Garbage Disposal YES ❑ NO p' Specifications for System: /o00 Cf U /��+� ili�,L
Auto Dish Washer YES � NO [DAuto Wash Machine YES NO �❑ .j 0 � � ��
0 .k .3 x /Z -S
Type Water Supply W _— ?�- [sem M C � ,�F ti
*This permit Void if sewage syste d s ribed below is not installed within 36 months from date of issue.
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FRONT
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
L>ctl
R
Certificate of Completion l- - Date 'J�
*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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name I ! f l ix
Date
Address ' a, 3Z7 Lot Size Z-ooX K'T'-j�
/U'Dwolui llfC 2?0 2fr
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ® S PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) (0> PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils e � PS PS
U U U U
4) Soil Depth (inches) S SS S
d!§) PS PS
U U U
5) Soil Drainage: Internal S S S S
dtp ' 17 PS PS
U U U
External S S S
4- Ti> PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S 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—U SU TABLE S—SUITABLE PS—Provisionally Suitab
Recommendations/Commen s.
���, Date
Described by Title
SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department y'
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
i / Home Phone 1701 "5 x1vy
1. Permit Reque ted By c r✓I tGa4her Business PhoneE-
2. Address l `7 m U i e /C o2 7o,)-a,
3. Property Owner if Different than Above Q_rn
Address
4. Permit To: a) Install ✓_ Alter Repair C ®o
b) Privy Conventional `/ Other Type +'
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House L/ 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 aa(Do Sq_ Sr -4
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 LA urinals garbage disposal
lavatory L showers 14 washing machine
dishwasher sinks ?_
8. a) Type water supply: Public Private t/ Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions a 0 O `4 4'�5 _S� '\-
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? NO
What type?
This is to certify that the information is correct to the 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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le - '4 on R %ds e C7 o pa
(?o . Lne UoI , to _D(:!,p4 , +o ISI 8 % roc,c(
Act n� -
�l�eceSer- n ;
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DCHD(6-82)