596 Gordon Dr Q
...K DAVIE COUNTY HEALTH DEPARTMENT
D CERTIFICATE OF COMPLETIO
; ��f�, •� � IMPROVEMENTS PERMIT AN I�
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 �� ati l Date /%�.'1r N2 5025
Locati n ��^ r:?^.,.i i1�r,,• ; hr's r,.� ;� : �- , �% % ..•� ��.i1't�.�ry �;�. /�1`'
_r
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 Specifica ions for System:
Auto Dish Washer YES NO
Auto Wash Machine YES g NO p _
Type Water Supply (40 _ ��i �--r� ��%do
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
i
Improvements permit by /La
*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
a
Certificate of Completion W" Date 6C�
*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.
l7,
V
1\�/ AP� CATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
V (� Davie County Health Department
Environmental Health Section99
R O. Box 665 RECMED .1 U M 2 Z
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
s3 oS"
\\ �� Home Phone �-
1. Permit Requ ted By n r �l� Business Phone
2. Address i7 CSI vv 1�eY;S
I,_ ' e5f.
3. Property Owner if Different than Above Ker\n j , d- (�C��^�� t 2. i act 'E' .
Address � 5 \. Q OO
4. Permit To: a) Install Alter Repa'
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot N
5. System used to serve what type facility: House Mobile Home. Business
IndustryOther
b) Number of people
6. ap If house or mobile home, state size of home and number of rooms.
House Dimensions ��-
Bed Rooms _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—e washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system ben approved? Yes No-L
9. a) Property Dimensions Q OLA_+ oIE w'\ Qo/ -P,
b) Land area designated to building siteJ
c) Sewage Disposal Contractor La L�
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? _
What type? a 8(A. 6 C
�kAn La.M�, crr.
This is to certify that the information'is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Go ( 5- �
-�\QAO"
(So I'doy._�) V cA-\- L
\ DCHD(6-62)
AW
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
,!,!! SOIL/SITE EVALUATION /
Name -/i'/' ( � Date
Address Lot Size ,1 14
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
2) Soil Texture (12-36 in.) Sandy, y
Loamy, Clayey, (note 2:1 Clay) U C t1
U
3
Soil Structure (12-36 in.)
Clayey Soils h JR— K 1319
U U `U
4) Soil Depth (inches) S
(t� U
5) Soil Drainage: Internal
S
U U U
External 4
Lpi) P PS
U U U
6) Restrictive Horizons
7) Available Space S S
$ PS PS PS
U U U U
8) Other(Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE —PS—Provisionally Suitable
Recommendations/Comments:
Described by «` / Title ,�`� Date �—
SITE DIAGRAM
"HD(6-82)