P3581 Pudding Ridge RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Se age reatment-and isposal Rules (10 NCAC 10A .193'4-.1/968) Permit Number
Name �/f < �.�' i/�' f�i' Date �L �± U 01
Location
(
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 p-" Specifi atio s or stem:
Auto Dish Washer YES NO ❑ -y
Auto Wash Machine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 onths 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:
dby (�.IR�Tti� ..,:1
a1► i; s -
D. Id .
Certificate of Completion Date 1 2 - 1 9 � V
'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.
14
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
ARFA 3 AREA A
FAC.TOPR
APPA i APPA 7
1) Topography/ Landscape Position
S
S
S
S
®
�
PS
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (�_.. :;—
S
PS
PS
cfa�:>
e_Z7
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
�) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
External
S
S
S
S
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
1) Site Classification
qU
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title ��`� Date
SITE DIAGRAM
41
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DCHD (6-82)
1. Permit F
2. Address
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
. R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 2 Q
rn Home Phone 71Q- qg_ J0 `4
!auested By �� , r P Business Phone q�Q- ��S— o� 3 �I
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 3
6. a) If house or mobile home, s to size of home anv number -of room . ,
House Dimensions
Bed Rooms Bath Rooms Den w/Closet J-�eAl Put�
b) If Business, Industry or Other, State: Number of persons serve
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water -using fixtures:
commodes a urinals
lavatory I;tl showers
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply s stem been approved? Yes No
9. a) Property Dimensions C Alb 091 oC Q-tAk o
b) Land area designated to building site
garbage disposal
washing machine
W
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? ___LQ—
What type?
This is to certify that the information is correct to the best of my knowledge.
g-
IAJ
Date Wwner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
i
W"J
DCHD (6-82)