151 Fernwood Lane Lot 21�. -, .. .. �_r..ir,.a. •x�[::Rlll. '4t��l:i. �* .t-.' a ty.v�'YW ... .t, • � .. a � It. • ..
a' •�:..'.. ti f.;.,;y.« t•..J .? :„4.2' �^..ap ::4 `•,.s, a ..4u r..i, ., ' � 1 - '..Y < <�.-�'
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: Issued in Compliance with G.S. of North Carolina Chapt r 130 Article 13c
Sewage Treatment and Disposal Rules /(10 NCA 10Q13� j968) Permit Number
Name
to
-
Location
Subdivision Name _
Lot No.
Sec. or Block No.
Lot Size House-- Mobile Home _ Business Speculation
No. Bedrooms _ No. Baths '7 No. in Family
Garbage Disposal, - YES E] NO p/ Specifications for System:
Auto Dish Washer YES [f] NO 'p -
Auto Wash Machine YES NO .E]
Type Water Supply
`This permit Void if sewage system described below is not -installed within 36 months from date of issue.
y
t
i
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspectign of this system between 8:30-
9:30 A.M. or 1:00=1:30 P.M..' on day of completion. elephone Number: 704-634-,5985.
Final Installation Diagram: /
System Installed by
D1,
Certificate of Completion L l%��� Date VA�
i
"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.
Y
J
f+
Y
i
Improvements permit by
*Contact a representative of the Davie County Health Department for final inspectign of this system between 8:30-
9:30 A.M. or 1:00=1:30 P.M..' on day of completion. elephone Number: 704-634-,5985.
Final Installation Diagram: /
System Installed by
D1,
Certificate of Completion L l%��� Date VA�
i
"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.
1-�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date C, 7�sv��
Address Lot Size ZC a
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/ Landscape Position
S
S
S
P
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
��
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
i) Soil Depth (inches)
S
S
S
$
PS
PS
PS
�f
U
U
U
�) Soil Drainage: Internal
S
S
S
pS
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
1) Restrictive Horizons
Available Space
S
S
S
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE -'PS—Provisionally Suitable
Recommendations/Comments:
Described by::12�/ Title �`� Date
SITE DIAGRAM
D HD (6-82)
• RECEIVED SEP
- 2 4 1986
• 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 liql - ?x,53
1. Permit Requested By rl/l/-i u "Ll Business Phone
2. Address 9f • l" Q c-)(, 1 Gro >Q jvt 1 �,ICv Ut C.( e) , n G X270 of
3. Property Owner if Different than Above '-a'Zh_eQmn'�
Address
4. Permit To: a) Installer Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division ea0�17-',QA - Lot No.
5. System used to serve what type facilif : House.L Mobile Home Business
Industry Other
b) Number of people Ak
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions JY06 1U `, L
Bed Rooms 3 _4 Bath Rooms a Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, eta
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes .2 urinals
lavatory
dishwasher
u
showers
sinks J
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions R/n A C-tc
b) Land area designated to building site
c) Sewage Disposal Contractor
garbage disposal
washing machine
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 orrect to the bet of y wledge.
Date Owner ignatu e
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Directions to property:
haw„ //,-Y A4W
DCHD (6-82)
Allow 5 days for processing
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