429 Hall Walker Ln (2) (n" _
' � ,•,a- - 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 "(1'0 NCAC 10A .1934-.1968).• . Permit Number
I amen _ .. .� 0` DateNO-
• - v �(zleto \YV5 �?103 - - .
..Location
JN
,at
t- J y:� - `.: -`::� ; -
Subdivision Name a''; ' �' Lot No:,,';' . k Sec: or Block No.
Lot,Size k�V�' -House Mobile Home �
eBusiness -- Speculation
No. Bedrooms No. Baths - _,No.'in'Family
GarbageDisposal YES .0 NO ❑ ," Specifications for System:.
Auto Dish Washer YES E) NO •'Q ; / o f c�
' Auto Wash Machine YES E] NO 'E)
Type Water Supply
"This permit Void if sewage system described below isnot installed within"36 months from date of issue.
_ ...i.. -
V
�. _:_--
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.
Ficial Installation Diagram:, System Installed b' 1i
s
Certificate'of Completion / 4 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
satisfactorilyfor.any given period of time'. .
RECEIVED AU6
4p, ot
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section 0
P. O. Box 665m
Mocksville, N.C. 27028
LECONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. (�
Home Phone%6,
1. Permit Requested By�,1LW(iC. 29Business Phone
2. Address Jq3 foo S EF_ES Sr-W1* SAP-1 X- 2 7/D
3. Property Owner if Different ton Above
Address
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 Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms a 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 l
dishwasher sinks t
8. a) Type water supply: Public Privatey/ Community
_ b) Has the water supply system been approved? Yes NoAZ
9. a) Property Dimensions
b) Land area designated to buildin site
�� rx
c) Sewage Disposal Contractor!.� o 04 � , 9F- �� b
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.4
'?Xa
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION �[
Name �•' `�-' Date
Address `�1�Lo 5A• Lot SizeX��V
W " S
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position 0) S S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, 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
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
Q% PS PS PS
U U U U
5) Soil Drainage: Internal Q S S S
PS PS PS PS
U U U
External S S S
PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SU PS—Provisionally Suitable
Recommendations/Comments:
Described by - Title Date " T1"
SITE DIAGRAM
DCHD(6-82)