147 Lakeview Road Section 2 Lot 491,
i.
DAVIE 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 Dispos I ules (10 NCAC 10A .1934-.1968) (; Permit Number
Name rr Jiia r r�r ; ' i Date
LocationX ,Fq%;i/� ) = rf,,", '`/ •�� li —
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�g -73 -3�1 IF
Subdivision Name Lot No. Sec. or Block No.
Lot Size ��1�irr _ House Mobile Home _ — Business __ Speculation
No. Bedrooms — No. Baths — No. in Family°` —
i
.Garbage Disposal YES NO 0 Specifications for System:
Auto Dish Washer YES [I NO. -E]
Auto Wash Machine YES [ NO I'vo, `
Type Water Supply
"This permit' Void if sewage system(described below is not installed within 36 months from date of issue.
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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: System Installed by
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OP
1.vi 4�.�.
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Certificate of Completion —_ 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.
' APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
-2 Home Phone 99p-
1. Permit Requted By. Business Phone 76S-d/Sr
2. Address .7`_ V x-'740
3. Property Owner if Different than Above
Address
4. Permit To: a) Install�Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Divisionz Sec.s2 — Lot No. Y-
5. System used to serve what type fa ility: House ✓Mobile Home Business
/ Industry Other
b) Number of people 'T
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 3''i Y SO
Bed Rooms 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 .3 urinals garbage disposal
lavatory showers r2. washing machine
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 316 " X -2-701
b) Land area designated to building site DV �c/e
c) Sewage Disposal Contractor 0A 'rf 6OrAml--Z r-
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? AjD
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:
DCHD (6-62)
f
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
AREA 1 AREA 2
Date 9 ?A;_-
Lot Size f �/4�
AREA 3 APPA d
1) Topography/ Landscape Position
5
6)
8)
9)
��-
S
S
S
( PSJ
PS
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
AREA 1 AREA 2
Date 9 ?A;_-
Lot Size f �/4�
AREA 3 APPA d
1) Topography/ Landscape Position
5
6)
8)
9)
��-
S
S
S
( PSJ
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
) Soil Depth (inches)
S
S
S
S
/ S
PS
PS
PS
U
U
U
) Soil Drainage: Internal
S
S
S
pS
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
Restrictive Horizons
Available Space
y
S
S
S
S
PS
PS
PS
U
U
U
U
Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6.82)
S—SUITABLE
Title
PS—Provisionally Suitable