237 Riddle Circle Lot 21DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION_
�1 *NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a -=
` , nSSaniWy Sewage Systems Permit Number
Name kAe/✓ AV7/- oV /q]ti�,i.r Date, -:219 IGjN2 5864
Location
Subdivision Name
Lot No. –o:2–/— Sec. or Block No.
Lot Size s ,<Ae House
Mobile Home — Business Speculation
No. Bedrooms ��S
No. Baths
*Q
No. in Family_ J
Garbage Disposal
YES ❑ NO
Specifications for. Systems
Auto Dish V%asher
YES
NO
❑
J�vQ� Z-
Auto Wash Machine
YES I
NO
❑
/ �C
Type Water Supply
CA/
*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 01/4/
*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
� �re
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
' Cj
Davie County Health Department
ction
Environmental
MockP. 0. BoxC6627$e�CE1Vv�F -z 2� 1990 g0-%10 i/�l/am',
//C
1. Application/Pi
Mailing Addre:
Home Phone
Business Phone 7 6 Z V 4 7
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: General Evaluation /ZL S/Tank Installation
S. System to Serve:' House Mobile Home 0 Business
Industry 0 Other 0 Unknown
6. If house, mobile home: Subdivision Sec/. Lot* o�
No. of People Dwelling Dimensions �1 /�
No. of Bedrooms a Basement/ Plumbing
No. of Bathrooms �_ L:Basement/No Plumbing
Washing Machine Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No, of People Served No.
No. of Commodes No.
No. of Lavatories No.
No. of Showers
8. Type of water supply: Public
9. Property Dimensions
10. Sewage Disposal Contractor
9
R
of Sinks
of Urinals
of Water Coolers
0 Private '0 Community
11. Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes A 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.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
2 I L 7 Af -&'U'a-
Date Signature.
Directions to Property:
a
DCHD (10-89)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot E
FACTORS AREA 1 AREA 2 AREA 3 ARFA d
1) Topography/ Landscape Position
9)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
I) Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS,
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
PS
U
U
U
U
q Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by
SITE DIAGRAM
DCHD (6.82)
S—SUITABLE
Title
PS—Provisionally Suitable
Date
r5
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name l� k1Ge 6 "�� Date 2, r
Address Lot Size
FAr:TORR AREA 1 AREA 2 AREA 3 AREA 4
) Topography/ Landscape Position
2)
a)
5)
6)
8)
9)
S
S
S
S
PS
PS
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,
�
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U-
U
i) Soil Structure (12-36 in.)
'<�
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
Soil Depth (inches)
�
pS
U
PS
PS
U
U
U
Soil Drainage: Internal
rc!t>
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
,�j
"---PS
PS
PS
PS
U
U
U
U
Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
U
U
U
U
Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE S—SUITABL PS—Provisionally Suitable
Recommendations /Comments:
CGrt Q
Described by K. X, Title
SITE DIAGRA
—=P. Ta P
DCHD (6-62)
Date 8''Z "13�
I
RQ A la
L