105 Cherokee Trail t DAVIE COUNTY HEALTH, DEPARTMENT .
'IMPROVEMENTS.;PERMIT•AND '.CERTIFICATE OF COMPLETION
r *NOTE: Issued in.Compliance with:G.S. of -North'Carolina Chapter 130,Article 13c. r `
Sewage Treatment and'Disposal Rules - .193 NCAC :10A- .1934-.1 68) ' :i�} Permit Number
Name ..__ LTJ >/ut� rr' Date .��c i'. (� 4�
Location l '�'.�+ /ry ' rr..� 2n' `�� ,f ` .f/�:.�/ / 1'' ��7' i e" •,r�,'
Subdivision Name-J) r11Yr%'r Lot No. ' Sec. or Block No.-.
Lot Size / s:t r y
House :Mobile Horne _ Business Speculation
No.'Bedrooms No. Baths No. in Family _
Garbage Disposal.' YES ❑ NO per'
Specifications for System:
'Auto Dish Washer'- . YES p . NO p
Auto Wash Machine YES NO
Type Water Supply / , "• y� �`_T/r/V
*This permit.Void if sewage system'described below is not installed within. 36 months from date of issue,
Improvements permit by
*Contact a representative of the Davie County Health Department foe final inspection of- this. system between 8:30-
•9:30 A.M.. or 1:00-1:30'P.M. on.day of completion. Tel phone Number: 704-634-5985. a
'Final Installation Diag"ram: :• System Installed by %ANN\ n a
0
W44
V
• i� • ' i
-Certificate of Completion ' '� Date 4L'
*The si nin of this certificatb4shall..indicate that the s tem described above'h .
• .., 9 9 ys, as.been.installed in'complianoewith .
the standards set forth in the above.regulation, but shall in'NO way be taken as a guarantee that ttie system will function
satisfactorily for any given period,of:time.''.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone Z 9- - 41
1. Permit Requested By JD`j r -Business Phone
2. Address c3 034-' S��Cern P.r �/I'd Alf. �'>2 Q-!T
�
3. Property Owner if Different than Above'�DI> o 0'il
Address Ea Y ;2 3 f -e kety 7r V a»0- hl 9761:6
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 Homed Business
Industry Other
b) Number of people e h a
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions X %�
Bed Rooms-Bath Rooms—Den w/Closet J
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 h r urinals - garbage disposal D
lavatory showers h �e washing machine d
dishwasher sinks ��n 'C-
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No-,e-'-
9.
om9. a) Property Dimensions
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? No
What type?
This is to certify that the information is correct to the best of my knowledge.
Date -Q_wmer-Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: ^�
17yi<
tel'�`cf' — � �s•6'y �%�� -` � .
DCHD(6-62)
Y
r DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Datet�"
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position �--� S S S
�/PSJ PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U
External S S S S
PS PS PS PS
U U U
6) Restrictive Horizons
7) Available SpaceS S S
4S 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
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �5 ~ �/� Title Date
SITE DIAGRAM
DCHD(6.82)