172 Ledford Trail 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 Date V - i 7 ." f41 4919
Location. i
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business, Speculation
No. Bedrooms _ No. Baths No. in Family 5
Garbage Disposal YES ❑ NO p Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by �'1�t
—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 Completions%`!
r
"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
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name S4-tA,�9-
Date
Address Lot Size -O-c-- t C3,34-
FACTORS.
d'-
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position e-� � S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ® PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils g!f1M> <2!!:n> PS PS
U U U U
4) Soil Depth (inches) S S S S
C!� PS PS
U U U U
5) Soil Drainage: Internal S S S S
-<a 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 S
[� c� 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—UNSUITABLEtt S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: 1y
Described by Title Date �✓Z� ���
,SITE DIAGRAM
a
a
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department Jv $,
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HA BEEN ISSUED.
Le Home Phone1. Permit Re uested By ecAn r � Business Phone
2. Address 7oL roQleernee VIJ,C– 0, 77/
3. Property Owner if Different than Above 4_0 7117, I r
Address
4. Permit To: a) InstallI Alter Repair
b) Privy Convention aU�_Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home ✓ Business—
Indust
usiness
ll Indust; Other
b) Number of people a` fts 3 c�„7ryeY\
6. a) If house or mobile home, state size of home and number of rooms. .
House Dimensions ag X 64C
Bed Rooms—Bath Rooms 2 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 urinals garbage disposal
lavatory showers / washing machine /
dishwasher l sinks
8. a) Type water supply: Public Private ✓ Community
b) Has the water supply system been approved? Yes✓No
9. a) Property Dimensions &r n_
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 is to certify that the information is correct to the best of my knowledge.
- � 3 -& !r
Date Owner Signa ure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
6 Cq/
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CG,;r_k-1 Y. l 14 -
DCHD(6-82)