180 Cable Ln •. -- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
~ IY*NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
Name 4/ /a,,�s � t < �;��� Date 4f N2 5803
Location f�/!_ .af�J'� �^�', r^ ,., 'r,/r,;, . /f 711"-'ty 11.i 11
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 ❑ NO Specifications for System:
Auto Dish Washer YES NO ❑ d
Auto Wash Machine YES [� NO ❑ ��� �. ' � ��r.
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.
Improvements permit bY �ell
*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. T lephone Number: 704-634-5985.
Final Installation Diagram: tem Ins I d by
,.
Certificate of 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,
r
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section c
P. 0. Box 665 R _CF
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 6-3 V-366 V
1. Permit Reques ed By O �� -+(i' �f Business Phone
2. Address T Z/(":?a h' ��c�c�-
3. Property Owner if Differ nt than Above
Address '� , /6W/-S U l /l/ GASfbllf e. r�
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 Home Bs
IndustryOther
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions /,a X
Bed Rooms 3 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 ZNo
9. a) Property Dimensions C20 0 X 0"00
b) Land area designated to building site
c) Sewage Disposal Contractor' sf�iz-
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 CO6or
E WITH ALL STATE AND LOCAL LAWS
Allow 5 dayrocessing
Directions to property: n
0 0 /Ud/TAL G7 �9�' / L 6'
p a A-c k o 1'
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*NOTE: Improvements Permits shall be valid for a period of 5
�i years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
I Effective October 1, 1989.
DCHD(6.82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
/ SOIL/SITE EVALUATION
Name 1Z e-1--1 n iL 5 Date 1 ��
Address Lot Size lNi
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) -FP
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils (?;�� (k &
U U
4) Soil Depth (inches)
P
5) Soil Drainage: Internal S � S
External S�
U
U
U U
6) Restrictive Horizons
7) Available Space S,
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:
Described by e&l Z Title Date
SITE DIAGRAM
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DCHD(6.82)