P5819 Casa Bella Drive Lot 43r DAVIE COUNTY HEALTH DEPARTMENT d
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
ii *NOTE: Issued in Compliance With Article II of G.S. Chapter 130a
Sanitary Sewage Systems Permit Number
Name � 1 i��c' , , <;ij , . -� Date / N2 5 0r.
Location
Subdivision NameLot No. Sec. or Block No. Y�
Lot Size House Mobile Home Business Speculation
No. Bedrooms '�, No... Baths r_ r No. in Family
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES ❑ NO [---
YES NO ❑
YES [�] NO ❑
Specifications for System:
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
/)Improvements permit by __�jC,�?
*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.
System S Instalfecf-6
Final Installation, -Dia ram: / r, �� y y
Certificate of Completion`-""F� 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.
Name—
Address
PAr.TnRc
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
APPA 1 APPA 9
Date
Lot Size .•�`����
ARFA 3 AREA A
Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
C�P
PS
PS
PS
U
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
PS
PS
PS
U
U
U
U
�) Soil Drainage: Internal
S
S
S
PS
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
S
S
S
PS
PS
PS
U
U
U
S) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
;�
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments: y
Described byTitle Date
SITE DIAGRAM
DCHD (6-82)
' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section z
P. 0. Box 665
Mockaville, NC 27028
1. Application/Permit Requested By a ��
�
Mailing Address cR)�'�
Home Phone Business Phone
2. Name on Permit if Different than Above
:3. Property Owner if Different than Above
4. Application/Permit For: l7 General Evaluation 2,,*/Tank Installation
5. System to Serve: C] House Mobile Home Business
L] Industry u Other Unknown
6. If house, mobile home: Subdivision IJ%,P•Sec. Lot#
No. of People '�%* Dwelling Dimensions NY -20
No. of Bedrooms _3 Basement/plumbing
No. of Bathrooms Basement/No Plumbing
m Washing Machine 91 Dishwasher 0 Garbage Disposai
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
-
No. of Showers
8. Type of water supply: 2-1:ru�blic 0 Private a Community
9. Property Dimensions z 6 C?%� -/�
10. Sewage Disposal Contractor L117 i)---
11. Do you anticipate additions/e�xpa cions of the facility this system is
intended to serve? [] Yes if'""
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this applicati. --,.
Date �,�' }% Signature
/
Directions to Property:
3
}
DCHD (10-89)