P3922 La Quinta Lot 5DAVIE COUNTY HEALTH DEPARTMENT i
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-)968) ,- Permit Number.
Name .;i' Date 2
,.
Location
i
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home .- Business __ Speculation
No. Bedrooms �'' No. Baths No. in Family--
Garbage
amily _Garbage Disposal YES ❑ NO ❑ Specifications for. System:
Auto Dish Washer YES ❑ NO ❑ ,�:,:', - r , �t
Auto Wash Machine YES ❑ NO ❑`�-
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue. a
i
--+---`_"-,_---------ter v t-/�
Improvements permit by
ice. �� i„'`��i j-•
*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'
J �
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.
1. Permit Requested By PC
2. Address c
Home Phone
Re..,A L 'r�, � - Business Phone 9o�-L / 0 d
3. Property Owner if Different than Above
Address
4. Permit To: a) Install !!t�_A Iter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-DivisionAA 1%1 wy-A SecI�FLot No.AR—IS"'
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 /y X 7 e
Bed Rooms -2— Bath Rooms 1 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
garbage disposal
washing machine Z
dishwasher f sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes-&L-No-
9.
esesNo9. a) Property Dimensions /0OX /S'<9
b) Land area designated to.building site
c) Sewage Disposal Contractor �� Al A T- -Z-
10.
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /y d '
What type?
This is to certify that the information is correct to the best of my knowledge.
4 ~ A V —As'
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
N.T f
DCHD (6-82) 1(
lq?
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name/��� ���"� y Date
Address — zt:;t��C� Lot Size /GfX/S'd
FAr.T0RC APPA i AREA 9 ARFA R ARFA A
1) Topography/ Landscape Position
S
S
S
OF
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
S
PS
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
4F
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S-
S
S
PS
PS
PS
U
U
U
U
!) Other (Specify)
S
S
S
PS
PS
PS
U
U
U
U
1) Site Classification
y
U—UNSUITABLE
Recommendations/ Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Pr e
Title ' �
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date a1'l�
Lot Size���s�
FAC.T()RC AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/ Landscape Position
&>
S
S
S
PS
PS
PS
U
U
U
U
�) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
ch>
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
i) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S.
S
S
CEP
PS
PS
PS
U
U
U
U
Q' Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
011012r
U—UNSUITABLE
Recommendations/Comments: ® ;ti/—
Described
—
S—SUITABLE
PS Provisionally Suitable
Described by :5�-- � _ Title Date A�y�err
SITE DIAGRAM
DCHD (6-82)