153 Cherokee Trail s DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article .13c
( Se ge Treatment and Disposal Rules (10 NCAC 10A .1934-.19 8) Permit Number
Name \ /Il��i% Date _� N2 3514
Locations <�s✓����
Subdivision Name Lot No. Sec. or Block No.
Lot Size House �obile Home _ Business Speculation
No. Bedrooms No. Baths _ No. in Family _
Garbage Disposal YES ❑ NO ❑ Specifications for S stem:
Auto Dish Washer YES ❑ NO ❑ ",, R 1 � v
Auto Wash Machine YES ❑ NO ❑
Type Water Supply
*This permit Void if sewa 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 Diagram: System Installed 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.
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: 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 ,/ / 1� �� i� Date �/� , ��/- 3 5 3 S 1 4
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House —L------Mobile Home _ Business Speculation
No. Bedrooms— No. Baths _ No. in Family--
Garbage
amily _Garbage Disposal YES ❑ NO ❑
Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES ❑ NO ❑ �����` `✓ ��`
Type Water Supply
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
/J
Improvements permit by
i
'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
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.
.J�'' DAVIE COUNTY HEALTH DEPARTMENT
` IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: 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 �, �� 1. — Date f j, /'/ ,i :: 3 J '14
Location
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 ❑
Auto Wash Machine YES ❑ NO ❑ ,
Type Water Supply 44 - __—
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements
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. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed 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.
DAVIE COUNTY HEALTH DEPARTMENT
' Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 05w 'e'- Date
Address � c%�7� Lot Size ?�
FACTORS. A�REEAA�1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position 'LSi S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS P PS
_
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U
4) Soil Depth (inches) S S S S
p PS P PS
U
5) Soil Drainage: Internal S S. S S
p j �PS PS PS
C'_% <T:) U
External � C> <ff> S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S
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—S ITABLE PS—Provisionally Suitable '
Recommendations/Comments: Zz
Describedb Title fL Date
A
A
CHD(6-82)
APPLICATION FOR SITE EVALUATION/IWIPHOVEMENTS PERMIT
} Davie County Health Department
Environmental Health Section
P. 0. Box 6(35
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENI'S PERMIT HAS BEEN ISSUED.
Home Phone__ '� k
1. Permit Requester! By 6V 1Business Phone
2. Address ,
/'%' ' �'
3. Property Owner if Different than AboveAddress. __-
4. Permit To: a) Install Alter Repair
b) Priv Conventional Other Type._—
Ground Absorption
c) Sub-Division-------- Lot No.—.-
5. System used to serve what type facility: House JMobile Homs Business
Industry_—...Cther____
b) Number of people. 4
6 a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms__c2..—.__ Den yr/C!oset_—..___ _
b) If Business, Industry or Other, State: Number of persons served
Whet 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
3. a) Type water supply: Public Private—�__Community
b) Has the water supply system been approved? Ye, No
9. a) Property Dimensions -1�.C�_L__ �.-- ---.----- _ —
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 th(. best of my knowledge.
?
_ 2 _
Date towner 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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OCHO(8.32) r