P4135 Gladstone Rd3
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 .1934-.1968) Permit Number
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Name%f ✓/'t"G�/,,r�° r; .�;�, -' _ Date —��}'f "'�'�� Ni 12 4 135
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size - 57 *F//(` House Mobile Home. 4-!�' Business Speculation
No. Bedrooms No. Baths �' No. in Family
—
Garbage Disposal YES ❑ NO D'
Specifications for System:
Auto Dish Washer YES NO ❑�', �,/ r' f j
Auto Wash Machine YES NO ❑ ; f Y
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 !3 a � Q
Sr1o9 — �0d0 - B
Co. W CZ4 er
Certificate of.Completion� ! �� L1 - ^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.
t1--2,0-WSJ
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
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 Co Gas
3. Property Owner if Different than Above
Address
4. Permit To: a) Instal
b) Privy
Alter Repair
Conventional Other Type
Ground Absorption
Home Phone 9b - a U 5 L9
business Phone C21 0y) 873 - a.a0 i
c) Sub -Division Sec Lot No. 1M V1 navJ — -00ct X
5. System used to serve what type facility: House Mobile Home—y—"Business—JJ
Industry Other—
b)
ther T use
b) Number of people �� d `
�0 k' � i1 c7us �2- trt�-e,t"
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions _ Q X yL
Bed Rooms— Bath Rooms— Den wfSfeset_
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 a urinals b garbage disposal
lavatory a showers t washing machine
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes Nom
9. a) Property Dimensions -Q.%3 () C-', P_
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? 2S
What type? ouS?_ � VU, ;, ")T, or - - dee C, r'
This is to certify that the information is correct to the best of my knowledge.
LQ- b-25 Colbjl-
Date Owner Sig ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
V\ 0,&Z"`ere—
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C C e.n.,►r� �,v.,un� �.� � � � � v0. 0. �r� � < ��;J � ��. v���-t, S .
aV\ j
9
DCHD (6-82)
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date �
Lot Size
AREA 3 AREA 4
AREA 1 AREA 2
1) Topography/ Landscape Position
&D
U
S
Tp
S
PS
U
S
PS
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
U
S
PS
U
S
PS
U
I) Soil Structure (12-36 in.)
Clayey Soils
S
PS`
P
U
S
PS
U
S
PS
U
i) Soil Depth (inches)
S
PS
S
PS
U
U
U
U
i) Soil Drainage: Internal.,S
(P3j
S
S
PS
�
'lT
U
U
U
External
S
PS
Li
S
PS
U
S
PS
U
S
PS
U
i) Restrictive Horizons
Available Space
Q�j
PS '
U
`FrS
U
S
PS
U
S
PS
U
1) Other (Specify)
S
PS
U
S
PS
U�
S
PS
U
S
PS
U
q Site Classification
U—UNSUITABLE
Recommendations/Comments:
uwavIlucu Uy _
SITE DIAGRAM
DCHD (6-82)
S -SUITABLE ( PS—` Provisionally Suitable