114 Long Meadow Rd Lot 23DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT- AND CERTIFICATE OF COMPLETION
VY,D
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
anitary Sewage Systems �) �� Permit Number
Name AJ. . N0 599
Location eil;111A
Subdivision Name Lot No. Sec. or Block No.�"
Lot Size House _- Mobile Home _ Business Speculation
No. Bedrooms No. Baths Z No. in Family _
Garbage Disposal' YES ❑ NO p- Specifications for System:
Auto Dish Washer YES T NO ❑
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.
A,,d
F-1
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 �,_& 4AX
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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested
2. Address
A,
, fA ,,
3. Property Owner if Different than Above
Address
Home Phone?/ V— 7.? V So5-3
Business Phone
4. Permit To: a) Install-iZAlter Repair % Ak
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division r'��1LGH� �Sec. 3 Lot No. _
5. System used to serve what type facility: Housed Mobile Home Business—
b)
IndustryOther /
b) Number of people �
6. aj If house or mobile home, state size of home and number of rooms.
House Dimen ions � X 6 0
Bed Rooms Bath Rooms -3 Den w/Closet_
b) If Business, Industry or Other, State: Number of persons served ff�(A
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes 3 urinals �� garbage disposal J11A
lavatory _3 showers washing machine i
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? ap�p/roved? Yesy No
—
9. 9. a) Property Dimensions a 1-, 391 i(- 3V:7 iL !ivy 41,2k r , / J Ai.z
b) Land area designated to building site t I- r_�f- Elder e'f 1-*! . � xcad p'eeci
c) Sewage Disposal Contractor She/Z I►AGN 1 WNN
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? No
What type?
This is to certify that the information is correct to the best of my knowledge.
Y//au"
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Vuf✓L CoAl�ace7/— 13UC--K
J20 dol 15 a plAo ra L am.
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DCHD (6-82)
Name—
Address
FA r .Tr1RC
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
e2d�—
Lot Size-/
ARFA 3 APPA A
ARFA 1 ARFA 7
I) Topography/ Landscape Position
d)
5)
�)
8)
9)
S
S
&�S
1�f -
P
P
U
!) Soil Texture (12-36 in.) Sandy,
S
S
ES
Loamy, Clayey, (note 2:1 Clay)
PSPS
"___o
L
U
1) Soil Structure (12-36 in.)
S
SC
U
S
Clayey Soils
PS
F S
PS
Q}�L
U
Soil Depth (inches)
S
S
S
PS ..
PS
U
Soil Drainage: Internal
S
S
S
S
PS
PS
i4
P
U
PS
U
External
S
S
S
P
S
U
Restrictive Horizons
�2 d
Available Space
PS
S
S
U
U
Other (Specify)
S
PS
S
PS
S
P
U
U
U.
Site Classification
S
I
U—UNSUITABLE
Recommendations/ Comments:
Described by '� f
SITE DIAGRAM
o�
DCHD (6-82)
S—SUITABLE PS Provisionally Suitable
t,P/a /. PV -e
Date