P3391 & P3395 Wood Valley Lot 81-' DAVIE 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
Z.
Name ,/r;�t' Date / /r-
Locationy ��f / ! �� ✓�/ j
Subdivision Name Lot No. -�� Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms No. Baths t2 No. in Family _
Garbage Disposal YES ❑ NO [a Specifications for System:
Auto Dish Washer YES [� NO ❑
Auto Wash Machine YES no 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
Certificate of Completion 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
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date —
Lot Size
Weo� (1R lie,
FArTORR AREA 1 AREA 9 ARFA R AREA A
6)
8)
1) Topography/ Landscape Position S S S S
4am> PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ®> I PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS
U �T" U U
1) Soil Depth (inches) S S S S
do PS PS
U U U
i) Soil Drainage: Internal Sisib S S
PS PS
U U U U
External Si S S
(RZ PS PS
U U U U
Restrictive Horizons
') Available Space S S. S S
<32�!> Q!s PS PS
U U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title ir/ Date
SITE DIAGRAM
DCHD (6-82)
i
Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date —
Lot Size
Weo� (1R lie,
FArTORR AREA 1 AREA 9 ARFA R AREA A
6)
8)
1) Topography/ Landscape Position S S S S
4am> PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ®> I PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS
U �T" U U
1) Soil Depth (inches) S S S S
do PS PS
U U U
i) Soil Drainage: Internal Sisib S S
PS PS
U U U U
External Si S S
(RZ PS PS
U U U U
Restrictive Horizons
') Available Space S S. S S
<32�!> Q!s PS PS
U U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title ir/ Date
SITE DIAGRAM
DCHD (6-82)
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title ir/ Date
SITE DIAGRAM
DCHD (6-82)
M APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
• Davie County Health Department
• Environmental Health Section
P O. Box 665
Mocl(sville, N.C. 27028
t\
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
(iarnp, rho.
1. Permit Reque By d Eau 19ess I? no _'�±_ EE
3. Property Owner if Different than Above V
Address
4. Permit To: a) Install �Alter Repair --
b) Privy_.. Conventional � Other Type,—
Ground Abs ion
c) Sub -Division Sec. Lot No.-�—'�'e'�' �'g 7'��
5. System used to serve what type facility: House Mobile Horne ti3'� usiness._._
Industry_ Other__
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms_. ____ Den w/Closet _
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amouniof waste daily (24 hours)--
7.
ours). 7. Number and type of water -using fixtures:
commAes _ urinals_ _ —_ garbage disposal _
lavatory showers_a _ twashing machine—
dishwasber .— sinks
S. a) Type water supply. Public -- F'riv4e _ Community
b) Has the water supply system been approved? Yes No_._.._
9. a) Property Dimensions --
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 cortify that the information is
best of
Date+ /Owner Signature
OWNER Iii SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWNS
Allow 5 days for processing
Directions to property: '
DAVIE COUNTY HEALTH DEPARTMENT.
IMPROVEMENTS. PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
S age eat- ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date
Location �z2f � /�� N 3395
Vo4
z
Subdivision Name Lot No. Sec. or Block No. /
Lot Size- House Mobile Home _ Business Speculationy
No. Bedrooms C No. Baths_ No. in Family
Garbage Disposal YES :Q NO p� Specifications for S tem:
Auto Dish Washer YES NO Q
Auto Wash Machine YES �j NO Q 1p�ya,
Type Water Supply G,� _—
*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 Cougty 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
Certificate of Completion 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.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS.. PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: -Issued in Compliance with G:S. of North Carolina Chapter 130 Article 13c
Sewage Tr�eatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date
Location✓1%.%� / "�,� __
3395
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
Certificate of Completion 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.
Subdivision Name
Lot No. �,�� Sec. or Block No.
Lot Size
House
Mobile Home if Business - Speculation
No. Bedrooms
No.
Baths
No. in Family _
Garbage Disposal
Auto Dish Washer
YES
YES
❑ NO
NO ❑
Specifications for System:
j
Auto Wash Machine
YES
$ NO
,
Type Water Supply
15 -
*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
Certificate of Completion 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
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FArTnP.q ARFA 1 ARFA 9 ARFA 3 ARFA d
5)
8)
1) Topography/ Landscape Position 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) C& PS PS PS
U U U U
i) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
1) Soil Depth (inches) S S S
PS PS PS
U U U
Soil Drainage: Internal S S S S
PS PS PS
U U U
External S S S S
PS PS PS
i =U U U U
�) Restrictive Horizons
Available Space S S S
PS PS PS
U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provision
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
Title >001-/ Date 10 -kr—
M
U—UNSUITABLE S—SUITABLE PS—Provision
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
Title >001-/ Date 10 -kr—
M
DAVIE COUNTY. HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: Issued in Compliance with G.S. of.North Carolina Chapter 130 Article 13c
Se ie-Treatment and Disposal Rules (10 NCAC 10A :1934�-.1 8) PermitNumber
Name Date _�J� N2 3891,
Location
Subdivision Name Lot No. U Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation l
No. Bedrooms `- No. Baths No. in Family
Garbage Disposal YES ❑ NO [ Specifications �Sy m:
Auto Dish Washer YES NO ❑ �/
Auto Wash Machine YES �] NO -❑ y i
Type Water Supply
*This permit Void if sewage system 'described below is not installed within 36 months from date of issue.
�06
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 byL,
Certificate of Completion 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.
DAVIE 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 fn 1 Dates l��� �'3691
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 p NO Ej
Specifications for System:
Auto Dish Washer YESNO
Auto Wash Machine YES P NO C]
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
vents 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
Certificate of Completion r= 1,01
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.
..+..-. ..l.e-_w.,`ryL..,., .:-. _,.-+r"�+...:,La'a •--;; R,...:..via••,.,v..±
DAVIE 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 %, , / Date
Location
Subdivision Name Lot No.� Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation-----
No. Bedrooms -
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply _
_ No. Baths No. in Family,
YES ❑ NO Ey-
YES
.-YES NO ❑
YES NO ❑
Specifications .for .System:
"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.
Certificate of Completion / 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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By L7 V = Al Business Phone -q U2, y0 U
2. Address >� D 'Pe ANLE .4.7d'16
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. -A 1016/EA Sec:f naLot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions / VX70
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 Z urinals
lavatory
showers c,4 -
garbage disposal
washing machine
dishwasher sinks
8. a) Type water supply: Public-'� Private Community
b) Has the water supply system been approved? Yes1-'-- No
9. a) Property Dimensions /DO X /.�D
b) Land area designated to building site Ce—n0 01—
c) Sewage Disposal Contractor e o r N R TL El"
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Af
What type?
This is to certify that the information is corTept to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
pr �T Allow 5 days for processing
Directions to property:
�1
Y
I
I
80/
I.rr
DCHD (6-82)
w'S