932 Yadkin Valley Rd � ..-- .. i .... - _ e'..:..sA f,./b , s ,•.. k.. !.. A.3o" O . .Iv :l A.- 4, v a.S:4k...tl 1. t. - k.ie • - —tls .. .-J. ..1`s''Y'R.,f..
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
+INOTL': Issued in Compliance withG.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and,.Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
r Name ��7��/,a %1' , _a`./ ,/�y/:'�; .%i/.f ��,;.;� Date
NO e
Location f
Subdivision Name Lot No. Sec. or,Block No.
Lot Size rl �l."
House Mobile Home _ .Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES p NO [T"
Specifications for Sstem:
Auto Dish Washer YES NO ❑ ,�/�C'l%1�`,�;./.%' �.:
Auto Wash Machine YES NO -p
Type Water Supply
*This permit Void if sewage system described below is not installed within 06 months from date of issue.
ty��
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.
� 1
Final Installation Diagram: System Installed by Z2���!�
;j
Certificate of Completion a` 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.
�/. APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
PP.
0. Box 665 RECEIVED OCT 1 7 1989
Mockoville, NC 27028. RE
V �
1 . Application/Permit Requested By /1/` �(` ✓wi< _
Mailing Address �� �� k 17Ce- �2-7o d
Home Phone ��$" 35 Business Phone (? ' 7� 7 ' a7o°D L`a.7�2(`
2. Name on Permit if Different than Above ' / I �j�`
/
3. Property Owner if Different than Above rye !�� Q- �� — 7)d -( �
4. Application/Permit For : L7 General Evaluation Q.,S/Tank Installation
5. System to Serve: House Lr] Mobile Home Business
Industry u Other Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People _ Dwelling Dimensions b 2 f wu S''ut
No. of Bedrooms . Basement/Plumbing
LJ
No. of Bathrooms ` Basement/No Plumbing
Washing Machine Dishwasher 0 Garbage disposal
7 . I.f 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 : 911public 0 Private 0 Community
9 . Property Dimensions � At. s
10 . Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? [3 Yes ErrNo
If yes, what type?
i *NOTE: Improvements Permits shall be valid for a period of s
I years from date issued. Improvements Permits are subject
�! to revocation, if site plane 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 applicati n.
Date - Signature
go I YA�I<:.\ L)'1-//, " a� "gl'q J—0 6' d �O 0
Directions to Property: VV
okky
�U C,9'T d C Ae X,A [/�C.�^ u J� W�t� ` /o n 1 !/ '�P�� d� C.
DCHD (10-89)
r
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name � � � Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ( S
T1 � � 'C7
2) Soil Texture (12-36 in.) Sandy, /�
Loamy, Clayey, (note 2:1 Clay) &U PS
U
U
3) Soil Structure (12-36 in.) S
Clayey Soils I '
r U
4) Soil Depth (inches)
( ' U
U
5) Soil Drainage: Internal Ste-,
PS �P�j�/
ExternalS
w -q <�' .
6) Restrictive Horizons
7) Available Space CS)-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 fs, 'S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by / Title �," Date
SITE DIAGRAM
Ilk
d
X
��S u
X 2
3 l
UCHO(6.82)