142 Alamosa Drive Lot 1DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION r
'NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a j
S niittaary Se age Systems / Permit Number
Name_�-�'s/J� r` �V�//�(� --- Date1� %i2 8180
Location
Subdivision Name %w� , / ��/ Lot No. _ Sec. or Block No.,%
Lot Size OHO — House.-- Mobile Home Business -- Industry
No. Bedrooms `--..No. Baths — _! - No. in Family _ Public Assembly Other
Garbage Disposal YES p- NO p' Specifications for System:
Auto Dish Washer YES Ea NO p /
Auto Wash Ma^hine YES [i] NO ❑ / D� / ^
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 - / `�i—�/
*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:
Jy51efT1 I1151d[WU Dywvw�-
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.
!� µ DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
- 'fVOTE isue'd in Compliance With Article II of G.S. Chapter 130a
Sanitary Se�+age Systems Permit Number
i. Date —11 f N2 8180
Location
Subdivision Name- � Lot No.
Sec. or Block No.
Lot Size T�'`-'11' �� _ House — Mobile Home _l Business __ Industry
No. Bedrooms '--E-- No. Baths — — No. in Family — Public Assembly Other
Garbage Disposal YES 0 NO p` Specifications for System:
Auto Dish Washer YES 0 NO 0 �/ r,,,// i f
Auto Wash Ma^hine YES j NO 0 '
Type Water Supply -- �' ----- --- '`�.' .�• �, `/ .� '. t<:
*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.
N
1'� • � o t`m •¢
l'
f
- 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.
Certificate of CompletionDate
'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
If
APPLICATION FOR SITE EVALUATIOWIMPROVEMENTS PE MI-� �n
` IE
Davie County Health Department V
Environmental Health Section D
P.O. Box 665 APR �►, /.
Mocksville, NC 27028
1. Application/Permit R quested By ` an
Mailing Addre�eb< ZZ Home Phone
Business Phone
2. Name on Permit if Different than Above
3. Application for: ❑ General Evaluation Septic Tank Installation Permit
4. System to Serve: ❑ House O'Mobile HomeII❑ LLPlace of Public Assembly
❑ Business r_-] Industry
Industry -❑ Other U LI5 U- knownb ¢ BLOI-l.F
5. if house, mobile home: Subdivision
)- A 9� / ;/I/ 1rte 19 Section,& M 5 L'ot # " A' F
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply: P-F�u'blic
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Private
8. Property Dimensions /0,2 X /S 0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes
•
❑ 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, 1939.
Directions to Property: 1
tax
This is to certify that the information provided is correct to t b t of my k wig , a
edn rderstand I am responsible for all charges
incurred from this application. �� i
DATE I SIGNATURE
CONSENT FOR $ITS EVALUATION IQ BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 QM 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.
DCHD (1193)
DATE SIGNATURE
❑ Basement/Plumbing
No. of People
❑ Basement/No Plumbing
3
No. of Bedrooms
0 --Washing Machine
No. of Bathrooms
215ishwasher
Dwelling Dimensions X G)
❑ Garbage Disposal
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
7. Type of water supply: P-F�u'blic
No. of Sinks
No. of Urinals
No. of Water Coolers
Water Usage Figures
❑ Private
8. Property Dimensions /0,2 X /S 0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve?
If yes, what type?
❑ Yes
•
❑ 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, 1939.
Directions to Property: 1
tax
This is to certify that the information provided is correct to t b t of my k wig , a
edn rderstand I am responsible for all charges
incurred from this application. �� i
DATE I SIGNATURE
CONSENT FOR $ITS EVALUATION IQ BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: ❑ 1. 1 QM 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.
DCHD (1193)
DATE SIGNATURE
Name_
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FAC:TORR ARFA i APPA 9 ARFA .q APPA d
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
e-PS3?
PS
PS
PS
U
U
U
U
S) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
I) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
S
.,�
PS
PS
PS
`
U
U
U
U
i) ;Restrictive Horizons
A
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
�^
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments: 0 '
Described byTitle Date
SITE DIAGRAM
wa
DCHD (6-82)