204 California LnDAVIE 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 Treatment and Disposal Rules (10 NCAC 10A .1934-.1 68)/ Permit Number
Name -CSC/,�.�' Date �S/ t� ''
�_. J3 4
Location
Subdivision Namer�J / Lot No. Sec. or Block No.
Lot Size ��/� Housey Mobile Home — Business Speculation
No. Bedroomsy No. Baths No. in Family S�
Garbage Disposal YES ❑ NO E1__ Specification sJorSystem:
Auto Dish Washer YES[)NO ❑ �/��j �,
Auto Wash Machine YES [ NO -❑
Type Water Supply_—
*This permit Void if sewage system descr
installed within 36 months from date of issue
Improvements permit by
y� .
*Contact a representative of the Davie o6t1,�y Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day f completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by �-rguvrr'
3, 1�p L`'
Certificate of Completion Date Z5
*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
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �, ��� Date
Address Lot Size
FAr.Tr1Rc ARFA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
S
&
S
PS
S
PS
cff:�
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
cvv-cpPS
S
S
U
S
PS
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey SoilsPS
PS
PS
PS
U
U
U
Soil Depth (inches)
S
PS
S
�
S
PS
S
PS
U
U
i) Soil Drainage: Internal
S
S
PS
S
PS
U
�T�
U
U
External
S
d
S
PS
S
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
`
S.
�
S
PS
S
PS
U
iT
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U/
Ute`
U
U
1) Site Classification
�•
��.
U—UNSUITABLE
Recommendations/ Comments:
Described bySITE DIAGRAM
P
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title Date
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMITJ-e,�'/,,e / °.c/
Davie County Healt' Department
Environmental Health Section
P. O. Box 665
MocksvillP,,,, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone �IIr2_1535
1. Permit Requested B L/ ��1 �' "�o Tile Business Phone
2. Address {tract Ian ��an /YIo�. �v;//c ,nl,0 , c `10CZf�
3. Property Owner if Different than Above
Address
4. Permit To: a) InstalljL!�Alter Repair
b) Privy I Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
—
b)
IndustryOther
b) Number of people -1-5
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 hours)
7. Number and type of water -using fixtures:
commodes e�2 urinals garbage disposal
lavatory t2 showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private munity
b) Has the water supply system been approved? Yes ComNo
9. a) Property Dimensions
b) Land area designated to building site c h e
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.
s" P,Date Owner Signature..
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
7w ffcl
DCHD (6-82)
[pO/ N6tJ-/1 tom
7-c, /_ "he
�o 60 -� yy
/l..l IJ e �-
�a ,.1 %6
rhe
k t
/ (S
M�c A u 1.1
CA , Rd,
/l.d, 60 6tJ1
l j �-- &a_Wle jF0 7 a e. pfio/., go L) S -p—
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