380 Stroud Mill Rd w •4sq y:�`,. 41.".:A1t E4, r'.r.3 ..w.l.. - _. .... ..,...J'..\.�.'. .. •. .'-
l�t'r D"IE COUNTY HEALTH DEPARTMENT ,�712AA)M,
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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 /Iri' �l�t;✓7/t c1> Date
Location >'%'�!>>—, T ?�i�r' f�� S_ �r .� 141 4211S"-T_ � �f;
Subdivision Name Lot No. Sec. or Block No.
Lot Size t � House Mobile Home _��� Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES p NO
Specifications for System-
Auto Dish Washer YES NO
Auto Wash Machine YES NO C7
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of,issue.
Y
U ,\
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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
v
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.
+ RE
CEIVED OCT 0 8 1986
.i APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
t Davie County Health Department b
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home pPhone e9 72- 6-636
1. Permit Requested By � Business Phone
2. Address GD /�" ,6.3 .51" _�'A 460 r—, /V)G 77
3. Property.Owner if Different than Above eaj,,t /7 eU e-&
Address R • /A /.3�>G IqZ 97'-f ta e � eG 77
4. Permit To: a) Install-jZAlter Repair
b) Privy Conventional_2�_Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home__ZBusiness
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /'� X & S
Bed Rooms _Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
;W. h1at type business, etc.
Estimate amount of waste daily (24 hours)
7. Number:and,type of water-using fixtures:
commodes urinals garbage disposal
lavatory I showers washing machine f
dishwasher sinks /
8. a) Type water supply: Public Privateer Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions -5 ��
b) Land area designated to building site
c) Sewage Disposal Contractor "Z)a d & Z ai. - 4714 b'o lei
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.
m-R - '�& 0 4 -az.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
ZYJ
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
•' Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size I
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
(19 PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note'2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils h PS PS PS
U U U U
4) Soil Depth (inches) S S S
AP PS PS PS
U U U U
5) Soil Drainage: Internal � S S S
Com' PS PS PS
U U U U
External S S S
PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space 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—UNSUITABLE S—SUITABLE PS—Provisi
Recommendations/Comments:
Described by Title Title Date
SITE DIAGRAM
L�
- 1
i"
DCHD(6-82)