997 Baltimore Rd (2) -•- • r-.+: -lYs.-.".• =s 5y --. a_._•a..vw.�" eJ- .:. - v r:c -t bt • « w a-_. _..- - _ _ _ • _____ _.- _.-.
00
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit cNumber
Name / 1"/:;, /r'f 5"_�'� J:;" r _C1 Date N2 7987
1-7
Location
Subdivision Name T Lot No: Sec. or Block No.
Lot Size Z _2!Z——— House _ 1--' Mobile Home --__ Business -- Industry
No. Bedrooms _.No, Baths — — No. in Family — Public Assembly Other
Garbage Disposal YES p NO
Auto Dish Washer YES NO p Specifications for System: pX
Auto Wash Ma^hine YES NO
Type Water Supply
'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
ATTENTION: YOUR SEPTIC SYSTEM CONTRACTOR MUST SEE THIS PERMIT/LAYOUT BEFORE INSTALLING THIS
SYSTEM.
i
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion.Telephone Number:704-634-5985.
Final Installation Diagram: System Installed by
1'
F�E"
Certificate bf Completion �_ '' 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.
D R
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERIV M
? Davie Count Health Department
Y p
,. Environmental Health Section
P. O. Box 665 j 9g
Mocksville, NC 27028
�ia.ri4 �"•.p � b `
1. Application/Permit Requested By. n <J" 0 n
Mailing Address S 7"7 Za n ng 0 7�'f S ac( Home Phone f0 3c/"
al e e ks t/r'de .0 C 70 a Y Business Phone 6131/11-5-13-1
2. Name on Permit if Different than Above 777-M Sm itoe
3. Application for: _/ E)General Evaluation ZYSeptic Tank Installation Permit
,(a
4. System to Serve: house ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
t
5. If house, mobile home: Subdivision A-P &k"S Section Lot #
❑ Basement/Plumbing
No. of People ❑ Basement/No Plumbing
No. of Bedrooms Er*ashing Machine
No. of Bathrooms &-Dishwasher
Dwelling Dimensions :5_ ❑ Garbage Disposal
6. If business, industry, place of public asse bly, 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 Water Usage Figures
7. Type of water supply: RAP*`ublic ❑ Private ❑ Community
8. Property Dimensions /-2. 'n-C&e.0 Sewage Disposal Contractor
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes V<0
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.
Directions to Property:
ss- -'a6►i (nee!-s� r'��e f� l��r►�d�,� � .
�R c��o�a.i� �u s fi Pa
be ZIP bpm,e o f he rs
e U�l�su�ch
'All
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.
DATE SIGNATURE
CONSENT FOR SITE EVALUATION TO BE DONE ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: 2111, 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
1 hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system. %
�— DATE SIGNATURE
DCHD(1/93)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksviile, N.C. 27028
SOIL/SITE EVALUATION �}
Name_ A,I1no, h/ Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S SS
51
U
2) Soil Texture (12-36 in.) Sandy, S S "
Loamy, Clayey, (note 2:1 Clay) (PSJ V PS
3) Soil Structure (12-36 in.) qS
Clayey Soils PS PS PS
4) Soil Depth (inches) S SS S C
U
U U
5) Soil Drainage: Internal S
PS
`lT l7
External �$
PS PS PS PS
U U U U
6) Restrictive Horizons „ J� J �,
7) Available Space Q
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification r • 5-. _ - , S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: -E'tA'a
Described by l�� Title 4 Date /-X Z1z1W
SITE DIAGRAM
ale 6-X7
Y
� 3
X
I �
UCHO I1.821