401 Oakland Avenue Lot 131` Y DAVIE COUNTY HEALTH DEPARTMENT; 1�
IMPROVEMENTS. PERMIT AND CERTIFICATE OFCOMPLETION ;
T. *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 4 028
Location�.J�a!�/.���
j ji h
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home '°'!* Business Speculation
No. Bedrooms_ No. Baths_ No. in Family,
Garbage Disposal YES 'p . NO Specifications for System:
,,Auto Dish Washer YES . i NO
Auto Wash Machine YES, NO Cl
.Type Water SupPIY ' • _ -- ��
: *This'permit Void if sewage system` described below is:'not installed within", 36 months from date of issue.:,
— ' —
a
Improvements Jpermit by
-*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
• ` ' fie, � � �..a...o�
7o i(
ID5r
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1 Certificate of Completion M11101VI Date „1 ` _ 1
'The signing of this certificate shall indicate thafthe: system describ above has been :installed.in compliance with
the standards set forth ihthe above regulation, but shall -in NO way be aken'as"a guarantee that the system will function '.
satisfactorily for any given period of time..
Name—
Address
'7L,je & C'-
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date��! L�
Lot Size
GAr:TnRC APPA 1 APPA 9 ARFA R APPA A
5) Site Classification ��
Topography/ Landscape Position 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) (SPS j PS PS PS
..0 ..... U U U
o) Soil Structure (12-36 in.) S S S S
Clayey Soils Ps PS PS PS
U-- U U U
Soil Depth (inches) S S S
l0 PS PS PS
U U U
Soil Drainage: Internal S ; S S S
SPS :. PS PS PS
U" U U U
External S S S S
` PS PS PS
�U--J U U U
i) Restrictive Horizons
') Available Space �S - S S S
PS PS PS
U U U U
3) Other (Specify) S S S S
PS PS PS PS
U U U U
�
U—UNSUITABLE S—SUITABLE
Recommendations/ Comments: o
ovally Suitable
Described by z!"� Title ,�Date
SITE DIAGRAM
DCHD (6-82)
U—UNSUITABLE S—SUITABLE
Recommendations/ Comments: o
ovally Suitable
Described by z!"� Title ,�Date
SITE DIAGRAM
DCHD (6-82)
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT Z�
Davie County Health Department I
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phonefd 3 4 7
1. Permit Requested By A74"P6-4-r/ ,{�S9it�e�l�P1 Business Phone
2. Address f-qc'7-. t,_K,_Q3Y _�.e A PAe C4,4..tlD ,f C- z9 7.2,P
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions R
a�
Bed Rooms Z- Bath Rooms Z 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
lavatory —
dishwasher
urinals
showers 'Z -
sinks
8. a) Type water supply: Public Private— Community
b) Has the water supply system been approved? YesX— No
9. a) Property Dimensions �� �"- � U
b) Land area designated to building site
c) Sewage Disposal Contractor
garbage disposal
washing machine I
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 to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH. ALL STATE AND LOCAL LAWS
Allow 5 days for processing .
Directions to property:
1
6CHD (6-82)
D a