474 Deadmon Rd Lot 1C)
DAVIE COUNTY HEALTH DEPARTMENT I
, 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
Namei e �� _ c� o N Date ci _ i ND E':`: -,, 0
�—�
Location s '� t. > r� y �C, ��\0s, _r'
�U\ S
Subdivision Name � etll V2.C'�~ �� - Lot No. — Sec. or Block No.
Lot Size / 00 i LF d 1 House Mobile Home _ Business Speculation V
No. Bedroom3
sy No. Baths �, No. in Family _
r
Garbage Disposal YES _❑ NO p- Specifications for System:
Auto Dish Washer YES ❑ . NO 0 Q-)
Auto Wash Machine YES �Z NO �❑ i
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date ofissue.
LJ
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 t y _
F
Certificate of Completion !
*The signing of this certificate shall indicate that the system describe
the standards set forth in the above regulation, but shall in NO way be
satisfactorily for any given period of time.
.� Date
above has been installed in compliance with
(en as a guarantee that the system will function
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
_ -Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone a �a
R -Z I -D s E
1. Permit Requested By i
--I I- %n Q^( Business Phone LL/N
2. Address N O c k S L" " ffi A 4c, oZ % v 2
3. Property Owner if Different than Above
Address
4. Permit To: a) Install v Alter Repair -
b) Privy Conventional / Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other 4 C < AP7,
b) Number of people
6. a7 If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms 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 1 urinals
lavatory —
dishwasher
showers
sinks
garbage disposal
washing machine
8. a) Type water supply: Public ;'-- Private Community
b) Has the water supply system been approved? Yes1::::�'_No
9. a) Property Dimensions I D O/ X 61=0 0 r
b) Land area designated to buildi ,site /9- /t
c) Sewage Disposal Contractor ! / A t? (:- 5't-FR'//C
�l
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 c rect to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�o(
(fA-) S �
DCHD (6.82)
. V_'Ot' A\ �
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name i� ���x-�-- Date 6
Address J x-.,` Lot Size 4,4(3 0
FACTORS AREA 1 APPA 9 ARFA A APPA A
t) Topography/ Landscape Position
S
�S
SS
(U"
S
PS
S
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
��
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)S
S
Clayey Soils
PS
PS
U
U
U
U
1) Soil Depth (inches)��
<i
S
S
PS
PS
U
U
U
U
i) Soil Drainage: InternalS
P
PS
S
PS
U
U
U
External
S
S
S
PS
S
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
U
U
U
U
I) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
&-!�)
U—UNSUITABLE
Recommendations/ Comments: n
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
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Title Date
0
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