504 Deadmon Rd Lot 4l .
I DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article Rot G.S. Chapter 130a '
Sanitary Sewage Systems 1 A1, 1, Permit Number
Name /� �., ;`�� " — L Date �� -//- % NO
7406
Location
Subdivision Name ('�f��`'' "�/ Lot No. :1Z Sec. or Block No.
Lot Sized House 1/ Mobile Home ________ Business Industry
No. Bedrooms No. Baths No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Ma shine 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.
Improvements permit by _L //,�LL—
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: -tem Installed
! T- 1 by� j�7�
F
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
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address V- q ,ted y 34""
S' Home Phone 9 S-7('—' `'?
Business Phone
2. Name on Permit if Different than Above 11
3. Application for: ❑ General Evaluation Septic Tank Installation Permit
4. System to Serve: 3/House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry
%% ❑ Other ❑ Unknown /L
5. If house, mobile home: Subdivision i%�(2 A- Section Lot # 7
No. of People
No. of Bedrooms --�
No. of Bathrooms G
Dwelling Dimensions /,�7, 6d = v 14
Y.
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Basement/Plumbing
❑Basement/No Plumbing
B"Washing Machine
Dishwasher
❑ Garbage Disposal
7. Type of water supply: nEl Public ❑ Private O� ❑ Community
8. Property Dimensions �J , vim Sewage Disposal Contractor T"x
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 3 --No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property:
Q
(o/S o v f� 7� �c•�1moh U1 a1. Co �� �, ���5
rC) U/G,Ph�,��s�
This is to certify that the information provided is correct to the best of my
incurred from this application.
Zwlf 5�
DATE
I understand I am responsible for all charges
SIGNATURE
CONSENT FOR SITE EV LUATI N TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: EO 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MU T be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE
DCHD (1 193)
SIGNATURE
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
-
Davie County Health Department
Environmental Health Section
... ....... .
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone � U (� - a 0a 6
1. Permit Requested By E PIM O'^( Business Phone Sryl► E
2. Address o O c ✓ oZ ic) 2
3. Property Owner if Different than Above
Address _
4. Permit To: a) Install Alter Repair
b) Privy Conventional ! Other Type
Ground Absorption Ghtu^3
c) Sub -Division Sec. Lot No. 40 k
5. System used to serve what type facility: House Mobile Home Business 'S 3,�v
Industry—Other—
b)
ndustryOther p�
b) Number of people 1 -
6. a) 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 I urinals garbage disposal
lavatory showers washing machine f
dishwasher I sinks i
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes1::::�'_No
9. a) Property Dimensions --1 D 0 0 0
b) Land area designated to buildi ,site
c) Sewage Disposal Contractor '-� A V ! �= S /_ / i C / %} of
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:
(f�� s
DCHD (8.82)
50 I_e _77�
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I
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name—
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Date
L- a� r M
Address
� �. `n`^ -'Q-Lot
Size
0 � k r U 0
J '
FACTORS
ARFIA 1 \ ARFA(1 ARFA 3 APPA A
1) Topography/ Landscape Position
PS
PS
S
PS
U
S
PS
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
P
PS
S
PS
U
S
PS
U
3) Soil Structure (12-36 in.)
Clayey Soils
PS
PS
S
PS
U
S
PS
U
1) Soil Depth (inches)
—
PS
�S
' n
U
S
PS
U
S
PS
U
i) Soil Drainage: Internal
S
P
U
S
PS
U
S
PS
U
External
p
k
U
S
PS
U
S
PS
U
i) Restrictive Horizons
_
') Available Space
�S��
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U
U
S
PS
U
S
PS
U
1) Other (Specify)
S
PS
S
PS
S
PS
U
S
PS
U
1) Site Classification
U—UNSUITABLE S—SUITABE ` PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title Date
SITE DIAGRAM
DCHD (6.82)