307 Rollingwood Drive Lot 4DAVIE 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 ii�,�✓J /;'i'Z-7` /�;C�,-� Date — s7 �425144
7
Location //� v �� , % f% - l ) /iii
Subdivision Name Lot No. ' -2-' Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms �, No. Baths No. in Family—
Garbage Disposal YES ❑ NO 0--' Specifications for System: 1 j
Auto Dish Washer YES NO ❑ ✓r . /'
Auto Wash Machine YES j NO ❑ (l �wX3X/�
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit 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:
t=
System Installed by
gS� '
Certificate of Completion �/✓�% Date 9/
*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.
J z
4 y� APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT�1 ppR i
Davie County Health Department SID,
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
y1 n/ c n Home Phone
1. Permit Requested By y��rV� ¢ • /ITS'/.5 TN C Business Phone
2. Address 119 ,FPD%
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter— Repair—
b) Privy_ Conventional— Other Type_ I j
Ground Absorption \
c) Sub -Division ; 06UTIIAMe S S c. Lot No. +�
5. System used to serve what type facility: House Mobile Home— Business—
Industry— Other—
b) Number of people 3
6. a) If house or mobile home, ystate size of home and number of rooms.
House Dimensionsg`a'P XZg
Bed Rooms 3 Bath Rooms 5- Den w/Closet
b) If -Business, Industry or Other, State: Number of persons served �0_14
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes 3 urinals a' garbage disposal
lavatory 3 showers 3 washing machine
dishwasher ! sinks
8. a) Type water supply: Public Private °� munity
b) Has the water supply system been approve ? Yes No—
:fd. a) Property Dimensions 2- 1—f' I� �'EA:g ,Re S
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? J?/y
What type?
This is to certify that the information is correct to the best of my knowledge.
112- )iR 2.
Date wne ' nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-62)
I
Address
DAVIE COUNTY HEALTH DEPARTMENT,
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
_ SOIL/SITE EVALUATION
Date
Lot
FACTORS AREA 1 ARFA 9 ARFA R ARCA A
1) Topography/Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
<y�$/j
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
lye
U
U
U
i) Soil Drainage: Internal
S
S
S
•
PS
PS
PS
may/
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
G—
Available Space
S
S
S
S
PS
PS
PS
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
l�1
Recommendations/Comments: - // �• -jiR ,—
Described by f �
SITE DIAGRAM
DCHD Je.e2i
Title
Date