594 Deadmon Rd Lot 3e � _
�rmit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
Fin
jF
Certificate of Completion Date �,,�2
'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'S
;
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
* NOTE:.Issued in Compliance With Article 11 of G.S. Chapter 130a _
Sanitary Sewage Systems
� J'
Permit Number
Name , \ C-, �,> .. �� ,r Zt:�S, Date j
v
Pio 1-7 3 1-7
2
Location a1 3 L 3 o ���sv \�E� }�� ,M1 . QZ
—�
_
Subdivision Name Lot No. Sec. or Block No.
Lot Size ) 00 k 4 vo' House ✓ Mobile Home —T Business __
Industry
No. Bedrooms --.No. Baths — No. in Family Public Assembly
Other
Garbage Disposal YES ❑ NO Q'
aS ecifications for System:
Auto Dish Washer YES NO
Auto Wash Ma^hine YES. NO ❑
C) v k I
„
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.
F
e � _
�rmit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-9:30 A.M.,
Fin
jF
Certificate of Completion Date �,,�2
'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 U,
Mailing Address i�l �f �ay Z%oZ Home Phone
Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation Septic Tank Installation Permit
4. System to Serve: L/ House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision . e '. , syr/ s Section Lot # 3
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 3 (Washing Machine
No. of Bathrooms Z LL [5/Dishwasher
Dwelling Dimensions ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers Water Usage Figures
7. Type of water supply: Public ❑ Private / ❑ Community
8. Property Dimensions 1 A, r-- Sewage Disposal Contractor / ( el
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 21 --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:
6vt //Y,e M,�/S
l /4✓�SG w% // /J2 O�/1 %�/jG [/1,J`' 17 / / v1 fC / !� �i�/�oc�C 4"I
This is to certify that the information provided is correct to the best of my knowledge, and I and stand I am responsible for all charges
incurred from this application.
//ZZ Z //`_3 2111�X,l
DATE SIGNATURE
CONSENT FOR SITE EVALUATION !Q BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST 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 SIGNATURE
DCHD 0/93)
ob�
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 CISS(UED.
Home Phone — q
1. Permit Requested By
R O .bi- Dm Business Phone ZT
2. Address o O c ✓ �/i= `t _C oZ iD 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.
o. 5. System used to serve what type facility: House Mobile Home Business
IndustryOther !� �• � � � X AP � • .k-
b) Number of people r-
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
I f
lavatory —
dishwasher
showers
sinks
garbage disposal
washing machine f
8. a) Type water supply: Public ✓- Private Community
b) Has the water supply system been approved? Yesk:�'_ No
9. a) Property Dimensions 1 Z> D / ?� /4- o o
b) Land area designated to buildiRsite /t
c) Sewage Disposal Contractor U A P
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? WO
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(
DCHD (8.82)
S0 _e -7-e
l
0
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
`SLS
\
Date
S
PS
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
Address
�'C�1 �'
S
PS
U
Lot Size
l
U�
c
FAr:TC1RS
A PrFA 1ARFI� AREA 3 AREA d
I) Topography/ Landscape Position
PS
�PS7'
S
PS
S
PS
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
451
S
S
PS
U
S
PS
U
S) Soil Structure (12-36 in.)S
Clayey Soils
PS
($---)
PS
U
S
PS
U
I) Soil Depth (inches)
PS
S
�
S
PS
U
S
PS
U
�) Soil Drainage: Internal
U
S
PS
U
S
PS
U
External
PS
S
PS
U
S
PS
U
�) Restrictive Horizons
Available Space
ii::)
U
S
PS
U
S
PS
U
o) Other (Specify)
S
PS
S
PS
S
PS
U
S
PS
U
i) Site Classification
U—UNSUITABLE S—SUITABLE LB E PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title Date'' O II
SITE DIAGRAM
UCNO (6.82)
9001
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