1031 Hwy 801 S• }.. - . J :: ... - � � . .) 1 f. �f ... � ice. t -
•DAVIE COUNTY* HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued In Compliance with G.S..of North Carolina Chapter 130—Article 13c.
Permit Number
Name W1201WA�.IV aRiz� c.c.e Date % I - 2.. `; 3061.
Location ��4f S'oui'!!F f^sS �r[cFNwuv� .c ��� CrrosS
-Pznr� �t Ua C F
Subdivision Name' Lot No. Sec. or Block No.
Lot Size A -C_ House Mobile Home ✓ Business Speculation
No. Bedrooms No. Baths ''No. in Family _
Garbage Disposal YES 1❑ NO ❑
Specifications for System: /000 crc %1 •
Auto Dish Washer• YES ❑ NO p C!
Auto Wash Machine YES lam' NO /GU X 3 ,x /Z 5�N f
Type Water. Supply �0UAIT --- '' - �� vri 4aN:coE,7C
*This permit Void if sewage 'system de cri ed below is not installed within 36 months. from date of issue.
K.if f SfZ- , or.. .SNALt.o . No rv%AitL SAN !Z�� CcsvE�Z
`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 lnstallation Diagram: '. " System Installed by Cg`
3 w
Certificate of Completion Date'
*The signing of this certificate shall indicate that the system, desc*dabove 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
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name RagwAAN OR -R£- (.L -766-6-71y Date 7 - ILS/ - Fir -Z-
Address
Address y%(oS A A/ S Lot Size /
C L f44AA%.c� PJ C 2-7o/2-
FACTORS
-7o/2
FACTORS AREA 1 AREA 2 AREA 3 ARFA d
1) Topography/ Landscape Position
(f)
0
S
S
PS
PS
PS
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy, - S� �� Z
S
&
S
PS
S
PS
Loamy, Clayey, (note 2:1 Clay)
SILT Go/1 /�•�
U
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
P
S
PS
S
PS
fcoe-A"y
(�9)
U
U
U
U
I) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
aS
S
PS
S
PS
15S
U
U
U
U
External
0
G)
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
6
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title S-AV17-A21.4A/
SITE DIAGRAM
-HD (6-82)
Date %-/Z-Fz
/6 o 'r
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address _17!�Z / 4–
Home Phone .4 016–(9 6–(9 f l
Business Phone
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 No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people— 1
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 hou
7. Number and type of water -using fixtures:
commodes urinals garbage disposal
lavatory % showers washing machine f
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yeses`
No
9. a) Property Dimensions
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
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