297 Oakland Avenue Lot 121DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules; (10 NCAC 10A .1934-.1968) Permit Number
Name Date
NO
Location —
_1
LS %
Subdivision Name-!t�_'f>> ��� -`�%' _ % n % Lot No. ,f Sec. or Block No.
Lot Size 11`'x'7`2 e 7•t"/7`House, Mobile Home _L� Business Speculation
No. Bedrooms
t� No. Baths No. in Family �--
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YES ❑ NO ®'
Auto Wash Machine YES ❑ NO ,Or�
Type Water Supply IJvG��i��/.
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by Z2,14
*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.
iiJ 1-1
Final Installation Diagram:
System Installed by
Certificate of Completion Date
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.
t APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS. PERMIT
Davie County Health Department �l
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
1. Permit F
2. Address
3. Property
Address
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absor tion
c) Sub -Division Sec. Lot N
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a} If house or mobile home, elate size of home and number of rooms.
House Dimensions
Bed Rooms c:72— 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
lavatory showers
dishwasher sinks
8. a) Type water supply: Public Private_ Community
b) Has the water supply system been approved? Yes NoX h 0 7�
9. a) Property Dimensions // ,7 X / C-0 k /D 7 X /
garbage disposal
washing machine
/ `i J'J r� (-C . -
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A/O
What type?
This is to certify that the information is correct to the best of my knowledge.
�' i.I-e - a / ;e:2 s
41 Date Owner Si nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6.62)
f
S
PS
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Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
/ ) SOIL/SITE EVALUATION
Date ,�� `7 �/V / 3'f�
Lot Size rd//I e-�
FA(.T(1RC AREA 1 ARFA 9 ARFA :i AREA A
1) Topography/ Landscape Position
9)
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?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
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PS'
U
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
US
SS
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S
1) Soil Depth (inches)
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PS
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US<05
1) Soil Drainage: Internal
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4
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External
S
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1) Restrictive Horizons
Available Space
S
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U
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1) Other (Specify)
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Site Classification
f/ V'
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U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title
/%dt Date