134 Alamosa Drive Lot 2DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
S��niittaary S age Systems /I Permit Number
Name , PaWE�/� / i �,/� " Date �'-f ' gS' N° 8181
Location
Subdivision Name A/O ;L r Lot No. Sec. or Block No. o�
Lot Size / AX!1:�� — House — Mobile Home _fL-- Business -- Industry
No. Bedrooms _No. Baths No. in Family — Public Assembly Other '
Garbage Disposal YES ❑ NO Q' Specifications for System:
Auto Dish Washer YESNO ❑ /Doi ��h .
Auto Wash Ma^hine YES �1 NO ❑ .-
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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
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.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
•Nt�TE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Namen t.-, .a t �, r�;>� — ._ Date'_T N2 8 1 U 1
Location
Subdivision Name Lot No. Sec. or Block No.
I -
Lot Size House Mobile Home —!G _ Business -- Industry
No. Bedrooms —.No. Baths No. in Family — Public Assembly Other
Garbage Disposal YES ❑ NO IT Specifications for System:
Auto Dish Washer YES �NO ❑
Auto Wash Ma,:hine YES NO ❑
Type Water Supply _` (10
*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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
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 byl -
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
riod of time. 1
�. satisfactorily for any given pe }
. v * APPLICATION FOR SITE EVALUAT4pjlsi_MPROVEMENTS PER.FIT V '
Davie County Health, Dopfinent V i
v=
Environmental Heap Seoi APR 'o
P. 0. Box 665 -
Mocksville, NG 2.7028
i
1. Application/Permit R uested By 1 �'
Mailing Address �� ,%, Home Phone c1
A I�J Li 6,V ty Al- Business Phone
2. Name on Permit if Different than Above
3. Application for: O General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House p'Mobile Home f� ❑ LLP,,lace of Public Assembly
❑ Business ❑ Industry ❑ Other B�� Unknowns%
' -r� r
5. If house, mobile home: Subdivision A �� ; � 1 _ Section/9L m S Lot # F
No. of People
No. of Bedrooms 3
No. of Bathrooms
Dwelling Dimensions
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Basement/Plumbing
❑ Basement/No Plumbing
0 Washing Machine
0161'shwasher
❑ Garbage Disposal
7. Type of water supply: 0-fru-blic ❑ Private ❑ Community
8. Property Dimensions 0 Sewage Disposal Contractor _
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes Er No
If yes, what type?
'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:
Ala,.ca Or
� 144 7)
This is to certify that the information provided is correct to
incurred from this application.
Q
DATE
of my kr}6wledgg, and'I�understand I am responsible for all charges
SIGNATURE
MUST CHECK ONE: ❑ 1. 1 OWN the property. ❑ 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 person 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
DCH0*V1V3)
SIGNATURE
Address
FAr.Tr1RC
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 1
Date gyp/
Lot Size
APPA 9 ARFA 3 AREA A
6)
8)
1) Topography/ Landscape Position S S S
AP PS PS PS
U U U U
�) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ,S ' PS PS PS
U U U U
1) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
AU U U U
d) Soil Depth (inches) S S S S
PS PS PS
U U U U
�) Soil Drainage: Internal S S S
-&�> PS PS PS
U U U U
External S S S S
PS PS PS
U U U
Restrictive Horizons
Available Space S S. S S
PS PS PS
Aq�> U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE SPS—Provisional y�lutah�
Recommendations/Comments:
I
I
Described by _
SITE DIAGRAM
DCHD (6-82)
Title --;renz Date .6ykf
U—UNSUITABLE S—SUITABLE SPS—Provisional y�lutah�
Recommendations/Comments:
I
I
Described by _
SITE DIAGRAM
DCHD (6-82)
Title --;renz Date .6ykf