P6196 Gladstone Rd ofu
a DAVIE COUNTY HEALTH DEPARTMENT �' /►
IMPROVEMENTS PERMIT- AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article 11 of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name ,tet :�t/. n%' lr:r' '�r fir '/ �/.,a ✓ Date _ZZ %> r" N2 6196
,.
Location 'e
Subdivision Name Lot No. Sec. or Block No.
Lot Size V L'' House Mobile Home _ Business Speculation
No. Bedrooms —? No. Baths No. in Family _
Garbage Disposal YES ❑ NO p"
Specifications for System:
Auto,Dish Washer YES NO ❑ G,G�
Auto Wash Machine YES NO ❑ _
Type Water Supply !A', --- .. z�D ?�/✓'.
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
Improvements permit by —� —
*Contact a representative of the Davie County Health Departme t fofinr al Inspection of this system between 8:30-
9;30 AM, or 1:00.1:30 RK on day of completion, Telephon u ber: 704.634.5985,
Final Installation Diagram: - — -- --- Sys a nstalled by V—_—�
At
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665 RECEIVED OCT 3
Mockoville, NC 27028
1 . Application/Permit Requested By // -
Mailing Address ,Q�`X LF 6?,
Home Phone Z`4- 2 214 / Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
4. Application/Permit For: lC) General Evaluation S/Tank Installation
hU s, 2 .Lz 0-�7-0
S. System to Serve: 2/House u Mobile Home O O�Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms _� Basement/Plumbing
LJ
No. of Bathrooms 2_ Basement/No Plumbing
Washing Machine J ishwasher 0 Garbage Dasposai
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
S. Type of water supply: /-' Public 0 Private 0 Community
9. Property Dimensions aCILQz9
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes No
If yes, what type?
*NOTE: Improvements Permits shall be valid fo_r 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 application.
V6 - 3 (- qo
Date Sig tura
Directions to Property :
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7
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DcxD (10-89) �1
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4: APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT '
Davie County Health Department
Environmental Health Section +�
P. O. Box 665 RGC�f '
Mocksville, N.C. 27028 G
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
--
Home Phone `��
1. Permit Requ sted By 7� ,UdR4a7'`' Business Phone
2. Address
3. Property Owner if Different than Above —
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type—
Ground
ype Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House—A!:'—'-Mobile Home Business
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 a z 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
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions A ct-cre.S
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.
—�ov—Y;/
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
! ' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
/ ) SOIL/SITE EVALUATION
Name �f��lC / Date
Address Lot Size c2ega
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
•.. U U U
4) Soil Depth (inches) S S S S
PS PS PS
U U U
5) Soil Drainage: internal S S S
PS PS PS
U U U U
External S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: d"
Described by 'A'�l� TitleDate
SITE DIAGRAM
R
DCHD(6.82)