Loading...
187 Jamestowne Dr DAVIE COUNTY HEALTH DEPARTMENT % U o -�- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NOTE:Issued in Compliance With Article I I of G.S.Chapter 130a " Sanitary Sewage Systems Permit Number Name 5�7 - . 7 �, Date �� >/7 N� J Location ` L Subdivision Name Lot No. Sec. or Block No. Lot Size 1461 House Mobile Home _ _ Business Speculation No. Bedrooms No. Baths –,*2 No. in Family Garbage Disposal YES ❑ NO 0- Specifications for System: Auto Dish Washer YES } NO ❑ y Auto Wash Machine YES [fj NO E] C1��-rte /r/rt.� -�/moo X-�',�'.�.� • �-e��y 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 revoctidln,if site plans or the intended use change. y Improvements permit by i O/� r *Contact a representative of the D ie County Heth Department r fib nal inspection of this system between 8:30- 9:30 A.M. or 1:00-1:30 P.M. on ay of complet' n. Telephone umber: 1)4-634-5985. / V Final Installation Diagram: a Z � stem Instal d by sx D. s ,. e 3.+ ' J i 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. ��(� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT V Davie County Health Department ISM` Environmental Health Section E�E��ED AN 1 2 10 P. O. Box 665 R Mocksville, N.C. 27028 CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. l� -sas- Home hone 1. Permit Requested By Business Phone 7 _Ce 1)- 3 10 2. Address &C 0_ t1j . 0, B 3. Property Owner if Different than Above Address 4. Permit To: a) Install Alter Repair b) Privy��Conven'tional Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House Mobile Home ✓Business IndustryOther b) Number of people s 6. ay If house or mobile home, state size of home and number of rooms. House Dimensions 14 X I 2� Bed Rooms_Bath Rooms L v Too r►, n 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 1=2 urinals garbage disposal n- lavatory A showers washing machine dishwasher sinks 3 8. a) Type water supply: Public • Private ✓ Community b) Has the water supply system been approved? Yes No W e A l `to b e d uS. 9. a) Property Dimensions b n ma 4 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 tocertifythat the information is correct to the best of my knowledge. Inn Date �— Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: - (o 4 t9 5� �� �r�vf9�z 1� l�d z'�� 7o / 1 i 1713 � '4tPv �rrrs DCHD(6-82) 4 DAVIE COUNTY HEALTH DEPARTMENT Environmental Heath Section P. O. Box 665 Mocksville, N.C. 27028 1 SOIL/SITE EVALUATION Name �" Date Address Lot Size FACTORS AREA 1 AREA 2 AREA 3 AREA 4 1) Topography/Landscape Position S S 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 PS PS U U U U 3) Soil Structure (12-36 in.) S S S S Clayey Soils PS PS PS PS U 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 U External S S S S PS PS PS PS U U U U 6) Restrictive Horizons 7) Available Space S S. S S 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 U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable s Recommendations/Comments: Described by l7 Q ZZ Title n Date I SITE DIAGRAM Y L r DCHD(6.82)