160 Wood Ln V
DAVIE COUNTY HEALTH DEPARTMENT1�
Rr' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewa a Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Dated L/ �� t
r '.1 -
Location<}!•!` ,< :-- >�r. '��;� ,�/
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Subdivision Name Lot No. Sec. or Block No.
Lot Size - 725 House-- �� Mobile Home _ Business Speculation
No. Bedrooms _,✓-- No. Baths _- No.,in-Family
Garbage Disposal YES p NO E�- ..
Specifications for System:
Auto Dish Washer YES NO Ej
Auto Wash Machine YES NO p Cr `�?'r•�/lc„y��
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit byrrl�/1
*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
Certificate of Completion ZZate
*The signing of this certificate shall indicate that the system describedlabove 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.
RECEIVED APR 2 8 1986
•' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN(ISSUED.
Home Phone
1. Permit Requested By v ` - Business Phone
2. Address T `'" O
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair?
b) Privy Conventional \-' Other Type
Ground Absorpion
c) Sub-Division , A'� Sec. Lot No. _
5. System used to serve what type facility: House 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_L �
Bed Rooms Bath Rooms Den w/Close
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 0 urinals garbage disposal
lavatory r�" showers washing machine
dishwasher sinks
8. a) Type water supply: Public PrivateCommunity
b) Has the water supply system been approved? Yes Z No
9. a) Property Dimensions
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?
What type?
This s to ce ity that the information is correct to the b st of my know) dge.
r-
D to Owner Signature Iry
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82) FE��� z21f
DAVIE COUNTY HEALTH DEPARTMENT
` Environmental Health Section
P. 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 S
PS PS
�� U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) 0— I PS PS
U U
3) Soil Structure (12-36 in.) ASS, S S
Clayey SoilsP P PS PS
U U
4) Soil Depth (inches) S S
pS PS PS PS
U U
5) Soil Drainage: Internal S S
PS PS
0" U U
External S S
PSCl' PS PS
U U
6) Restrictive Horizons IZZZ7�
7) Available Space S S S S
S PS PS
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—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(8-82)