P5850 Gladstone Rd DAVIE COUNTY HEALTH DEPARTMENT >
i _IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION Q•����1�, �����
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems \ \ 3 7 _ o Permit Number
Name �-� L t-1 L� l �2 Date / N2 5850
Location
`l \ �.,b�i Com_'3_.)"1�— f �.i -Jam�•...\.,,1� ��/ n CV.✓T
Subision Name '�.� Lot No. Sec. or Block No,
Lot Size 1 -_L,- House Mobile Home _ Business Speculation
No. Bedroomsy — rx
No. Baths �" No. in Famil
Garbage Disposal' YES ❑ NO E11_1� Specifications for System:
Auto Dish WasherYES ❑ NO [
� _ "�_•;,-. ��.«�,
Auto Wash Machine YES_ M/NO ❑
Type Water Supply .:,
*This permit Void if sewage system described below is not installed within 5 years frorr"i date of issue.
This permit is subject to revocation if site plans or the intended use change.
1 CJ
O Q .
0 Q
Impr ve .ents 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 IN d s-�e&y
Certificate of Comp tion Date
"The signing of this certificate shall indicate that the syste described above has bee• installed in compliance with
the standards set forth in the above regulation, but shall in 0 way be taken as a guarant�(e that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Z., Environmental Health Section
_----''
P. 0. Box 665
� fksville, NC 27028
\
1 . Application/Permit Requested By
Mailing Address -21, 2 -�4-------------------
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above �e�
4. Application/Permit For: D General Evaluation eS/Tank Installation
5. System to Serve: House Mobile Home 0 Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms 2. Basement/Plumbing
of Bathrooms / Basement/No Plumbing
Washing
Machine Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: @Public 0 Private Q Community
9. Property Dimensions :
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? Yes No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify, that the information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this applica-t?.io
Date ` /Signature
Directions to Property :
EOl
'i
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE
\EVALUATION
Name Qn "R,�N Date 90
Address Q Lot Size 1• �`�`
FACTORS AREA 1 AREA AREA 3 AREA 4
1) Topography/Landscape Position S S
S
U U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay) PS PS
U
3) Soil Structure (12-36 in.) S
Clayey Soils PS PS ct
U U
4) Soil Depth (inches) S
PS U Com'
U U U
5) Soil Drainage: Internal S S
11-00
(ZAD, C-Jr-o 1�0
PS
U U U
External S
1p�>
AJU U
6) Restrictive Horizons S\1.113° _
O V�
7) Available Space S � - (S
PS ISS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification �j S
U—UNSUITABLE S—SUITABLE c PS—Provisionally Suitable
Recommendations/Comm
Described by Title �� S ' Date -�
SITE DIAGRAM
Flo
DCHD(5.82)