P5109 Fairfield Rd DAVIE COUNTY HEALTH DEPARTMENT
"w rl ;IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOT14: 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 tr, �:a Y . �,;,�t�5 �, "� Date `� �. L}
Location
Subdivision Name Lot No. _ �' S66. Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms y No. Baths No. in Family --�
Garbage Disposal YES ❑ NO p Specifications for System:
Auto Dish Washer YES [;5 NO
4,
Auto Wash Machine YES p NO -❑
Type Water Supply
s
*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 Diagr*am: System Installed by
Certificate of Completion ;�G. � 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
r Th Davie County Health Department �`��
Environmental Health Section GG�O
`-' P. O. Box 665 R`
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN
/ISSUED. p�q'
Home Phone
1. Permit Requested By Z Business Phone
2. Address O 0
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventionaly 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
6. a) If house or mobile home, state size of home end number of rooms.
House Dimensions Do2kL e- 0 f Cj e, ?
Bed Rooms a?&15 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 machiney
dishwasher ? sinks
8. a) Type water supply: Public V1 Private Community
b) Has the water supply system been approved?( e ✓ No
9. a) Property Dimensions 31* acres "
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: /
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DCHD(6-82)
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MARGARETF. CLEMENT
D.B.115 PG.620
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N 85' -161 25f E --► NIP
PIP 65.02
W. P. ARNOLD AREA = 0. 500 ACRE
DIB-58 PG-607
DB.63 PG.105
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION �(CN.
(
Name c CSS Date
Address Lot Size
FACTORS ARE 1 AREA AREA 3 AREA 4
1) Topography/Landscape Position S S S
lT– Io PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey SoilsPS� PS PS PS
(tls U U
4) Soil Depth (inches) S S
S PS PS
U U U
5) Soil Drainage: Internal S S
PS PS PS
U U U
ExternalS S
PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S - S S
p PS PS PS
U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification S
U—UNSUITABLE S—SUITABLE PS— rovisionaliy Suitable
Recommendations/Comments:
Described by \e�` C c� Title Date a 1 0 1
SITE DIAGRAM
DCHD(6-82)