133 Oak Tree Drive Lot 133 & 134DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued in Compliance ,-with .G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name y .- 11 -3 9 �.�t��o tZ Date 4 Z . 4.Q°#
Location
Lot No. IS, g 13V Sec. or Block No
Lot Size h House Mobile Home _ Business Speculation
No. Bedrooms -3 �I No. Baths No. in Family '
Garbage Disposal DYES ❑, NO ❑
Specifications for System: /000
Auto Dish Washer iYES ❑ NO ❑ r A,
Auto Wash Machine �IYES E]NO
zoo x 3 K i k Z7,00C
Type Water Supply �»� M avr, r� --- .� - px U �/ � nJ� rz Z
`This permit Vo iif sewage system described below is not installed within 36 months from date of issue.
Improvements permit by F
*Contact a representative of4he 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.
i
Final Installation Diagram: h System Installed by Q,�-
y. S
j.
Certificate of Completion XYM/ J4 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 penod� of time.
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' APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT����
r 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 7a4 73' Z•f��%
1. Permit Re uested By �'�' + �' , SeZeo* me E Business Phone
2. Address - /Z_ 27". 72A/-,* It •a ••. ?1% • 1 677
3. Property Owner if Different than Above
Address
4. Permit To: a) Install±!:'_' A Iter Repair
b) Privy Conventional Other Type
round Ab sor n >>_
c) Sub -Division Sec. Lot No,L7L3
5. System used to serve what type facility: House Mobile Homeletff-business
IndustryOther
b) Number of people 7--
6. a) If house or mobile home, state size of hom and number of rooms.
House Dimensions
Bed Roomsy3 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 urinals garbage disposal
lavatory showers washing machine �-
dishwasher sinks —�
8. a) Type water supply: Public Private Community--
b)
ommunity-b) Has the water supply system been approved? Yes No
9. a) Property Dimensions (' �r d 0
b) Land area designated to building site
c) Sewage Disposal Contractor It a k #4o w
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 correct t he be knowledge.
r L
Date "-"'ow& Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Directions to propert
DCHD (6-82)
Allow 5 days for processing
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Homes Inc.
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name V I V I SIZiAA-10P-r, Date S'- /dy- Q"Z-
Address fq. 1-L g x A Lot Size X / 0 0
✓I cc C N 2Ft6?'7
CAr^Tnoe AREA i AREA 9 ARTA A
ARFA 4
Topography/ Landscape Position
S
S
S
S
S
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Q—
S
S
S
Loamy, Clayey, (note 2:1 Clay)
CP
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils(
PS
PS
PS
-f
U
U
U
i) Soil Depth (inches)
y
yz y&y PS
S
PS
S
PS
S
PS
U
U
U
U
i) Soil Drainage: Internal
0
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
N��
') Available Space -
PS
S.
PS
S
PS
S
PS
U
U
U
U
3) Other (Specify)ck,
S
PS
S
PS
S
PS
U
U
U
U
�) Site Classification
U -UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S -SUITABLE PS -Provisionally Suitable
Title _SA rel,, / n,52 (A,0 Date &- /�'ke