P5326 Cedar Grove Church Rd-,,:........—.,..++rte•-.-,.,,. .A...:.,.a;.. �. w _ a: �,,s.._ .����. .� . `vi:. .f _ _; : ;, ;,,. .:. ... . _ '-�., ' � P .. _. .. ,
DAVIE COUNTY HEALTH DEPARTMENT
(10,
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION \
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c Am4vfelv [ `�
Sewage Treatment -and Disposal Rules 10 NCAC 10A .193 -.1968. Permit Number
20
g p (, � )
Location %�
Subdivision Name Lot No. Sec. or Block No.
Lot Size �C' House Mobile Home Business Speculation
No. Bedrooms =2 No. Baths _ No. in Family
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
*This permit Void if
YES ;❑ NO ❑
YES ❑ NO ❑
YES ❑1 /ANO C❑
( f,
Specifications for System:
.rte
36 months from date of issue.
*Contact a representative i' of the Davie County Healtla De
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Tel
Final Installation Diagram'
Improvements permit by /�,
ment for final inspection of this system between 8:30 -
one Number: 704-634-5985.
Installed
// b
L�
I
Certificate of Completion Date • E' "i
*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 Section CEjWp STEP 3
P O. Box 665 RE
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Re nested By`'.mc,_ e.S Business Phone 43U- a3 -S4.
2. Address I (L x at, A1C. Q.) na.$
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot Nom—
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
b) Number of people
6. ar If house or mobile home, state siz) e of home and number of rooms.
House Dimensions I XA4
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 i garbage disposal
lavatory 1 showers washing machine 1
dishwasher sinks 1
8. a) Type water supply: Public_ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions S acre
b) Land area designated to building site
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 correct to the best of my knowledge.
F..e- Esc ten.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
V
DCHD (6-82) /e"M
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksvilie, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FAr:Tr1RS ARFA 1 ARFA 9 ARFA 3 AREA A
Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Solis
P
PS
PS
PS
U
U
U
U
Soil Depth (inches)
S
S
S
S
PC
PS
PS
PS
U
U
U
U
1) Soil Drainage: Internal
S
S
S
S
P
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
') Available Space
S
P
S.
PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
P
PS
PS
PS
U
U
U
U
I) Site Classification
U—UNSUITABLE S—SUITABLE PSS—_Provisionally Suitable
Recommendations/Comments:
Described by _ Title
SITE DIAGRAM
DCHD (6.82)
9
0