191 Crestview Dr -Tw
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
K Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit ,Number
Name .�� , ; \ z., Date `. r
Location
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Subdivision NameN64 dew _bk Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in,Family _
Garbage Disposal YES'
❑ NO Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES ❑ NO
Type Water Supply Q_ _
"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.
Final Installation Diagram: System Installed by
S
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.
DAVW'
VILLAGE
Residential Care Facility
Hwy.64 East
P.O.Box 1092
Mocksville,N.C.27028
JERRY L COOPER Tele.# �Q1 A}�39R—h�R1
* —J4
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 RECEIVED MAY-71 191
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested Byylry 1164el P&-cjet310 Carn Business Phone Q9g-1#24
2. Address1•I�,.tnv aq EQ64 ��n BnX 104.0 M'0r_WStl1l4' AI P. 2 02'R
3. Property Owner if Different than Above e,
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
Industry Other
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
owim Dimensions 24 k .3(o
Bed Rooms Bath Rooms—Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc. Mannee_r_< e4icP Q6 Dny�ey 11rasei
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
8. a) Type water supply: Public �`l� Private Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions I•h Gtcres
b) Land area designated to building site
c) Sewage Disposal Contractor
G.
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? N 0
What type?
This is to certify that the information is correct to the best of my knowledge.
049 W-11 g 6kfA
Date V aner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow,5 days for processing
Directions to property:
N kwoLy c9 Lt C0.s+ _ U5+
• J tj ,G; Armory + Smal�
CI^urch _ lura r15ht ort ►'feta
�r«vel roae( _ 51�e �Oca�c�
�oP ov k;(( ov\ rtc�k{,.
PrOPerfy boundary jfnes are e�+ab(Isd►ed 1�
w o rak1se aq 5
tce 61 ��q5$ Ctrl o�
DCHD(6-82)
g ravel road . l u wefr 3tde o� �4c_1114y KPgr Rett
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name d � C Date ^�
Address Lot Size r
FACTORS AR!gZ� AREA' AREA 3 AREA 4
1) Topography/Landscape Position S S S
P3'1 PS PS
U U U
2) Soil Texture (12-36 in.) Sandy,. S S
Loamy, Clayey, (note 2:1 Clay) SPS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS U PS
U U
Zq
4) Soil Depth (inches) S S S
—459S PS PS
Jul U U U
5) Soil Drainage: Internal S S S
P /1105PS PS
U �j' U U
External �S , � -S S S
n PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
PS PS PS
U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE S—Provisionally Suitable
Recommendations/Comments:
\ - , rte
Described by Title Date
SITE DIAGRAM
1_
C71
DCHD(6-82)
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