139 Ginny Lane Lot 4VO)(
. 3$ [>20
ter;' DAVIE COUNTY HEALTH DEPARTMENT
is
m ; IMPROVEMENTS PERMIT AND CERTIFICATE_ OF COMPLETION
'NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
anitary Sewage mSystems Permit Number
Name r /�P/i�P�Ya �f ,��/� /?/. Q�� Date /�9s� N2 5-8
Location
Subdivision'Name/P Lot No. Sec. or Block No.
Lot Size s % /-;L House ✓ Mobile Home — Business _-- Industry
No. Bedrooms_�.No. Baths— No. in Family _ Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for ySystem: �^n
Auto Dish Washer YES NO ❑ /ODS P^ /u/Jo
F�6to Wash Ma".hine YES NO ❑
Type WaterESupply _.„.np
'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
1r
"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:
G
System Installed by
w
_
b
took CertificaIte•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 §hall inWO way be taken as a guarantee that the system will function
satisfactorily for any given period of time:
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS
" Davie County Health Department
' Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By G 1 /\4e v7/ J&°.� e '� — /J o % e PC) fl / LJ44lf�
Mailing Address /-�� Al6vll �F0I Home Phone
AJV2-hee-. IVC- A7006 Business Phone 9io-p5k-'?3a5L
2. Name on Permit if Different than Above `-Lb e ( 6!P-
3.
!83. Application for: ❑ General Evaluation AfSeptic Tank Installation Permit
4. System to Serve: [ House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision S� LV v Section Lot #
No. of People Z
No. of Bedrooms -3
No. of Bathrooms
2
Dwelling Dimensions X�
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
I.. .9 •uu..II
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
7. Type of water supply: A Public ❑ Private
8. Property Dimensions • 16 &C)V- Sewage Disposal Contractor
❑ BasemenUPlumbing
❑ Basement/No Plumbing
Washing Machine
Dishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes W No
If yes, what type?
❑ Community
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:
/,SFI 40 Red/�+Ivd vi,k.-f o)v gbtitlort
le>tl ory V%Ivivy IMIle 3�4 104 01V W4
This is to certify that the information provided is correct to
incurred from this application.
7 /- 9 (�- �
DATE
of my knowledge, and I understand I am responsible for all charges
TURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 2 • I 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.
SIGNATURE
DCHD (1193)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORR AREA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
C�9:>
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Z�>
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
I) Soil Structure (12-36 in.)
Z:T)
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
Soil Depth (inches)
( f>
S
S
S
PS
PS
PS
PS
U
U
U
U
Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
U
ExternalS
PS
S
S
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
U
U
U
I) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
3) Site Classification
U—UNSUITABLES—SUITABL PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title
SITE DIAGRAM
d
N
,
DCHD (6-82) IRA %
Date e—Z--"