1428 Bear Creek Church Rd,
' DAVIE COUNTY HEALTH DEPARTMENT !> t
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE:- Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal tRules (10 NCAC 10A .1934-.1968) Permit Number
Name �` �.\5�(c��a�(\ ��� V) Date y N2 5530
Location
SubcFivision Name Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home _ Business ,� Speculation
No. Bedrooms 'I No. Baths 2.5 No. in Family ___ LA_
Garbage Disposal YES ❑ NO IR/Specifications for System:
Auto Dish Washer YES [gl NO ❑ >, , -, V _ . - 4'
Auto Wash Machine YES g-- NO ❑
Type Water Supply
"This,permit Void if sewage system described below is not instal
witl 36 months from date of issue.
^� r
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 ��`t� DateZ/2/1_
"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 Section9
P O. Box 665 RECEIVED APR 1
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested, By Q h Qi3 � 2 U. !'l Nct e�esa.✓
2. Address ���40 601(181-
ox181 (11deksu,(�i
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
R
Home Phone 70V —49'2-7/6'7
Business Phone 9'/ 9 - 7 26 -77/5
OZ$
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people y
6. al If house or mobile home, state size of home and number of rooms.
House Dimensions
f
Bed Rooms_ Bath Rooms 2 �Z 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 2 washing machine 1
dishwasher ) sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes Noly
9. a) Property Dimensions 21 acAeiJ
b) Land area designated to building site 2�
c) Sewage Disposal Contractor `� frd66�e
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Nd
What type?
This is to certify that the information is correct to the best of my knowledge.
tj
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��� CZE S o �N,eN-� to d -ees o Date
Address s Q�-0- Lot Size a c R QS
FA(`TOP-Q AREA 1 AREA 7 ARFA R ARCA A
1) Topography/ Landscape Position
PS
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2) Soil Texture (12-36 in.) Sandy,
Loamy, CI^ayey, (note 2:1 Clay)
CUP
U
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U
< PS1
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3) Soil Structure (12-36 in.)
Clayey Soils
PS
U
t) Soil Depth (inches)
S
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i) Soil Drainage: Internal
U
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External
(Z!k
-6,
PSPS
U
U
i) Restrictive Horizons
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Available Space
S(S
1-4�
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
P
1) Site Classification
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\�S� —
U—UNSUITABLE S—SUITABLE
Recommendations/Comments: WQa --a A-3 ) -�O 1 (
Described by ��- Title
SITE DIAGRAM
DCHD (4-62)
PS— rov)sionaliy Suitable
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Date `7f -a) - 9- 9