164 Sonora Drive Lot 12DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION�,q�
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a j
.Aanitary Sewage Systems Permit Number^i)p
Nam' ` e7`�s` /" : ;' /% �`%�;%i . , f" ,�`U Date � %� /_ /J;7
NO 7040
Location?/i
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home 1% Business _— Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO 4 Specifications for System:
Auto Dish Washer -YES ❑ NO
Auto Wash Ma shine YES ❑ 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.
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
. r.
Certificate of Completion } b t 3
*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
—'NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .193,44-./1968) Permit Number
Name Gtr aeyl" 'l%, `/f Date 9 N2 5674.
Location
Subdivision Name ��11I& Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms %_f No. Baths Z7 No. in Family_
Garbage Disposal YES .0 NO Specifications for System:
Auto Dish Washer YESNO
Auto Wash Machine YES $ NO
Type Water Supply 01
*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:
System Installed by
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.
1
• APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS. PERMIT
Davie County Health Department t ON.
Environmental Health Section G(
P. O. Box 665 p�i4
Mocksville, N.C. 27028 rr
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
.Home Phone
1. Permit Requ ted B d ed L7 Business Phone � T A/0O
2. Address v'09 w
3. Property Owner if Different than Above
Address
4. Permit To: a) Install 'Alter— Repair
b) Privy Conventional •* Other Type
Ground Absorption
c) Sub-Divisid�m N1g9 Sec. Lot No.—L—Q) °e4c- I V -k_4-7
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people_
6. ar If house or mobile home, state size of home and number of rooms.
House Dimensions IV X 70
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 urinals garbage disposal
lavatory showers washing machine
dishwasher l sinks
8. a) Type water supply: Public —Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /.A0 X /(/& X'/0 / )( /3f
b) Land area designated to building site E AGk 100�
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is corr to the es of my knowledge.
IAO
�9
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to p
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Name—
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 ARFA d
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
A
U
U
Name—
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 ARFA d
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
.
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey SoilsPS
$>
PS
PS
U
U
U
t) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
') 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
1) Site Classification
r
U—UNSUITABLE S—SUITABLE �S—Provisionally Suitable
Recommendations/Comments:
Described by ��� Title �,/��� Date
SITE DIAGRAM
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