118 Alamosa Drive Lot 4VYO
DAVIE COUNTY HEALTH DEPARTMENT; To
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
S Hilary ewa a Systems Permit Number
Name -q DateY N° 7579
Location�i✓�'� n"�-`���t'`' .�%���rs" f� `., /` S l4-
Subdivision Name
Lot No. '� Sec. or Block No. T
000 44:
Lot SizeHouse Mobile Home Business -- Industry
No. Bedrooms S. No. Baths —c2--" No. in Family_ Public Assembly Other
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES NO ❑ /�?�t/ �'57
Auto Wash Ma thine YES NO ❑ / i �,
Type Water Supply
'This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
I
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.,
1:00-1:30 P.M. or*4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by
r -
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.
4
APPLICATION FOR SITE EVALUATION%IMPROVEMENTS PE MITL a n�j
`1-%6 � Davie County Health Department (}
Environmental Health Section V
P. O. Box 665 .APR 0
Mocksville, NC 27028
1. Application/Permit R nested By -
Mailing Address (`) �� �� Home Phone
q'y t e-- ill, L' , Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation Septic Tank Installation Permit
4. System to Serve: O House rd'Mobile Home n O LPlace of Public Assembly
O Business O Industry O Other II�� UnknownD f BL0G4F
Pr
S. If house, mobile home: Subdivision )- A a�l ; /-V )g SectionA% m S Lot # y "F
O Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms 3 0 -Washing Machine
No. of Bathrooms 26lshwasher
Dwelling Dimensions /y X ❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served No. of Sinks
No. of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply: Q-V'ublic
8. Property Dimensions woe X /-S 0 ? Sewage Disposal Contractor
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Private
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
Yes
RM
❑ Community
*NOTE: Improvements Permits shall be valid for a period of 5 years from date issued. Improvements Permits are subject to
revocation, if site plans or the intended use change. Effective October 1, 1989.
Directions to Property: 1
Ala,
f4- 5i
6 t.V�AL -D 6' 6� �
This is to certify that the information provided is correct to
incurred from this application.
DATE
of my
SIGNATURE
I am responsible for all charges
CONSENT PSNH aE EVALUATION M aE DONE 0 ABOVc, DESCRIBED PROPERTY
MUST CHECK ONE: O 1. 1 OWN the property. O 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a perbon authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (i/93)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) 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)
PS
PS
PS
U
U
U
3) Soil Structure (12-36 in.) '
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
I) Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S.
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
r
9) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE �—Provisio
Described by Title — Date
SITE DIAGRAM
DCHD (6-82)