732 Chinquapin Rd (2) LL 'rw ,, '. -�. `..��-:. ....,. .v. 5—..-y" 'a.;.'+'+•%• tJ'^i11N u..Wil:e:._'ha� -� nr al .,. s'S ..a. e...n"s i .t > .. ,. ,.. -.
DAVIE COUNTY HEALTH DEPARTMENT V IMPROVEMENTS PERMIT PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposa Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �s �' 2 - L Date � ` R 5 NO 5650
Location 5 cb a� 1 o s o U t)
Gol N
y .
• ,irt
Subdivision Name �Lot Sec. or Block No.
Lot Size +���` House Mobile Home Business Speculation
r F
No. Bedrooms 3 No. Baths No. in Family-
Garbage
amily Garbage Disposal YES ] NO'C21''L Specifications for System:
Auto Dish Was het YES `(2/ NO p G '--
Auto Wash Machine YES W.NO
Type Water Supply _
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
k
VV
Improvements
permit by(l � ���'� � • �`��
"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 �� � --,
IOG' �vPN
160 ,
lao'
Certificate of Completion ` Cis- . Date,. ` - a U /
"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
1' ,n Davie County Health Department o'FCOW-]
V � Environmental Health Section R.—
R O. Box 665
Mocksville, N.C. 27028
CONSITRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone S S'
1. Permit Requested Be44Business Phone /
2. Address !I� C.
3. Property Owner if Different than Above
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 Homes
IndustryOther
b) Number of people p�
6. 4 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 Cl? urinals D garbage disposal
lavatory a showers a washing machine
dishwasher sinks //
8. a) Type water supply: Public Private JZ Community
b) Has the water supply syster een approved? Yes No
9. a) Property Dimensions– -- f y
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 Si nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: ��tt ,,J /'
` 110M /�lee&l/Ile (�D �o�/ `hwao adk, u�����
0 C4 I tuAo Le
ap A) )V (d UO a5l F
r� e r� 10; 1�� /�aUe
GO abod m•`/e aA �e�t y
Red jaj
Cl 0 -
mat e, eJ
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION c
Name J Q ��� - �\�\( �-t e 1�)Q Date
Address vim- Lot Size 4
T
FACTORS AR 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils <ZJS S PS
U U U U
4) Soil Depth (inches) 4P S
S S PS
U U U U
5) Soil Drainage: Internal tS
4��i; (ZN I PS
U U U U
External. S
`PSS PS
U 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
C c U
9) Site Classification JJ S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ omments: ga-1
Described by - Title �c Date
SITE DIAGRAM
G 1
DCHD(6-82)