P5838 Underpass Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
r`NOTE:.Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage `Systems Permit Number
Name \� \-il �. Date F� i - I �.) N2 5838
Location
Subdivision Name Lot No,. / Sec. or Block No.
Lot SizeHouse Mobile Home _t'` Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO
Auto Dish Washer YES ❑ NO [ Specifications for System:
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 issue.
This permit is subject to revocation if site plans or the intended use change.
Improvements permit
*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
1 F�
J4U
7
T)
)regulation,
ertificate of Completion' - \�` \��i Date I /U
"The signing of this certificate Vdd
te that the system described above has been installed in compliance with
the standards set forth in the abut shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given periof time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
j Environmental Health Section
P. 0. Box 665
Mockaville, NC 27028
Ige-
1 . Application/Permit Requested By I' P� _ ,04Y
Mailing Address A9fi,2 U& ����_��.yi/� & /�
Home Phone F4,— 0/4 Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: 0 General Evaluation Tank Installation
5. System to Serve: 0 House Mobile Home 0 Business
Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms a Basement/Plumbing
No. of Bathrooms . _ , Basement/No Plumbing
*,**'Washing Machine J Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type
No. of People Served / No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: 0 Public • rivate Q Community
9. Property Dimensions
10. Sewage Disposal Contractor ,
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes. . 0 No
If yes, what type?
*,NOTES 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 trice
gest of my knowledge, and I understand I am responsible for all-
charges incurred from .this application.
Date Signature
Dire7t:.,.on: to Property :
1
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
~ Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address <; Lot Size
FACTORS AR6A 1 ARE AREC3 ARE 4
1) Topography/Landscape Position S
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay) P PS PS S
U
3) Soil Structure (12-36 in.)
Clayey Soils PS PP PS
U U
4) Soil Depth (inches)
PS PS PS
U
5) Soil Drainage: Internal S /
U U U
External
pS PS PS P
U U
6) Restrictive Horizons �---�
7) Available Space S (;S-)
S
PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
9) Site Classification
U—UNSUITABLE S—SUITA PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date C) ' U_
SITE DIAGRAM
�2
DCHD(6-82)