P5218 Granada DriveDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name %—TY��,�1 �L /'r ��Date.� e�LL
A.
Location
is//� .4", i, �.rri' ..fw. �• �,� !�>/s-y_,../-;i��' l'.1. �i ir'.f �. ,r .r �/ �+-
Subdivision Name X f Lot No, Sec. or Block No.
Lot Size `� House .� Mobile Home Business Speculation
No. Bedrooms yNBaths —_ No. in Family _
Garbage Disposal YES .fl NO Di
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES [ NO p
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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.
Find Installation Diagram:' System Installed by
Cert
*The signing of this certificate shajl indicate
the standards set forth in the abo a regulatic
satisfactorily for any given period of time.
f _
'icate of Completion_ -y- Date
hat the system described above has been installed in compliance with
, but shall in NO way be taken as a guarantee that the system will function
e) w�
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS. PERMIT y t
Davie County Health Department eY Ma
e Environmental Health Section G�
P. O. Box 665
Mocksville, N.C. 27028
"CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
p Home Phone c�
1. Permit Requested By �iJJcf- 1` y �' Business Phone
2. Address `N . C
3. Property Owner if Different than Above �'�I ►`� �s t-
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 D,
6. aT If house or mobile home, state size of home and number of rooms.
House Dimensions I i -I x —70'
Bed Rooms 3 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 urinals garbage disposal
lavatory showers ( washing machine
dishwasher sinks Z
8. a) Type water supply: Publics Private Community
b) Has the water supply system been approved? Yes_CZNo/
9. a) Property Dimensions�� 4
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 Signa
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: L A, L I- ( Rl g , a 5"1 -7
ChNre�- ��� � turn � �K�rnx• Y5'
o�7y%�K
c�eQ 7a ke- -7-), i s road c%aci
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Go asf-}"enn i s enUr-i-s � `71ien a.
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an
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44* . - . .- 4
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
llvecz Date
Lot Sizee
FAIrTnRS AREA 1 AREA 2 AREA 3 ARTA 4
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
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey SoilsP
PS
PS
PS
U
U.
U
1) Soil Depth (inches)
S
S
S
S
p�
PS
PS
PS
�j
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
(p�
PS
PS
PS
��
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify) n !l �/gC
PS
(
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:.
Described by ✓ c�0Title"' Date
SITE DIAGRAM
UCHD (6-82)