P5047 La Quinta Drive• DAVIE COUNTY HEALTH DEPARTMENT �0,
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
' NOfE: Issued in Compliance with G.S. of #�-£ a Chapter 130 Article 13c
Sewage Treatment and D' os
al Rules (10 NCA A .1934-.1968) Permit Number
toName jiar7
Location,"-"
Subdivision Name % oeS:� ? Lot No. Sec. or Block No.
Lot Size House ►- Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family Z__
Garbage Disposal YES ❑ NO D- Specifications for System:
Auto Dish Washer YES NO "❑ ,Ci? �%y .
Auto Wash Machine YES W NO ❑
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
f
1-2
Certificate L Co pletion _7�`� Date/t
*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.
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.
<16(j) Home Phone 9'9 X - C IP -11 i
1. Permit Requested By DANNH ORP, FN Business Phone 63 </
2. Address /olo? La Q s,✓ 7`a DP A0V4"VCr iv. c 0,6'
3. Property Owner if Different than Above c A.2 L ofd ]-0i9,,u C
Address ?/22 O La Q e --l' , f.) ev.c- a7oo
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-lCMobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Iqo C,
Bed Rooms_9 Bath Rooms l 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
lavatory
urinals garbage disposal
showers / washing machine
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No ✓ /
9. a) Property Dimensions 209 - O 3 — I Q V" 3 / — f y- .9 9 — // D ` 9 8
b) Land area designated to building site /r g f 20
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? NO
What type?
This is to certify that the information is correct to the best of my knowledge.
Date ner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
�j SOIL/SITE EVALUATION
Name— Date
Address Lot Size
FACTORS ARFA 1 AREA 9 AREA '3 ADCs A
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
lye
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
4) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
ly/
U
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
>) Restrictive Horizons
') Available Space
S
S
S
S
PS
PS
PS
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
4 -
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments: t�—
Described by�� Title
SITE DIAGRAM
UCHD (5.82)
Date