P3627 Cherry Hill RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatme t and Disposal Rules (10 NCAC 10A .1934-.1/968) Permit Number
Name �Ir%,� fitDate67
i J
Location r ! ��.: �i� =/ f
Subdivision Name Lot No. Sec. or Block No.
Lot SizeiT House Mobile Home --Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications Qr. System: J
Auto Dish Washer YES [:]NO ❑'�/'--a '� "Y
Auto Wash Machine YES ❑ NO ❑J`
Type Water Supply _
*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.
- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
SewageTreatme t and isposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name r C^4-"4 ' Date "fn ,y< D' , 3627
Locationj1
Subdivision Name Lot No. Sec. or Block No.
Lot Size !' �` House Mobile Home --- Business Speculation
No. Bedrooms No. Baths -� No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications ,for System:
Auto Dish Washer YES ❑f NO ❑
Auto Wash Machine YES ❑ NO ❑
Type Water Supply _—
*This permit Voi� 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.
f-
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT -a
`
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address
Home Phone O
Business Phone
3. Property Owner if Different than Above lav LQd r a -PXX l
Address
4. Permit To: a) Install Alter Repair
b) Privy ConventionalI Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 1 G
Bed Rooms 3 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 sinks
8. a) Type water supply. Public Private ✓ Community
b) Has the water supply system been approved? Yes No ✓.
9. a) Property Dimensions 116 :2 5-
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? 1 10, ie461i r , laC
This is to certify that the information is correct to the best of my knowledge.
Dafe ND
OWNER IS SOLELY RESPONSIBLE FOR CO IAN E HALL OCAL LAWS
Allow 5 days for processing
Directions to property:
601-.s ;6--
&I - ga)LJ6L,&
pp/c� &4,L/
DCHD (8-82)
,.'4
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name—
Address
CA Prnoc
APPA i APPA 7
Date
Lot Size
ARFA R ARFA A
Topography/ Landscape Position
SS
S
PS
S
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
Clayey Soils
S
S
PS
PS
U
U
�) Soil Depth (inches)
S
PS
S
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U-
U
U
i) Restrictive Horizons
') Available Space
S
PS
S.
PS
S
PS
S
PS
U
U
U
U
3) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
�)
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS Provisionaliv SuitahiA
Described by Title Date
SITE DIAGRAM
5
DCHD (6-82)
Name—
Address
GA r.TnR C
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION I-
Date 4P 7 Y -
Lot Size 5;gy'
AREA 3 AREA 4
AREA i ARFA 9
Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
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 Soils
PS
PS
PS
U
U
U
)Soil Depth (inches)
S
S
S
S
PS
PS
PS
C�
U
U
U
U
) Soil Drainage: Internal
_�
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
P
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
S
') Available Space
S
S.
PS
S
PS
S
PS
U
U
U
I) Other (Specify)
p
S
PS
S
PS
S
PS
U
U
U
U
i) Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by
SITE DIAGRAM
P
DCHD (6-82)
S—SUITABLEProv_ isionaliv S��)+anlP
Title
Date