P5249 Old Mill Rd ID
DAVIE COUNTY HEALTH DEPARTMENT 9-
` • IMPROVEMENTS PERMITI AND CERTIFICATE OF COMPLETION
OTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatm nt and Disposal Rules (10 NCAC 10A .1934-.1968) J Permit Number
Name sr1L'r .��',�r �� 40'/ „-„� � Date 712 55 24-9-
Location X`.�'r .,�! c %��«. .�', ,r': j,✓ // -
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family �S
Garbage Disposal YES p NO 2r Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO p
Type Water Supply _
'This permit.Void if sewage system described below is not installed within 36 months from date of issue.
r ,
Improvements permit by -' �r +' �
"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- 4-9985.
Final Installation Diagram: System Installed y �a
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 .0
Davie County Health Department
O
Environmental Health Section cc[r�tt,
R O. Box 665 �GVG
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/ Home Phone ?evS etllz
1. Permit Requested By J t' Business Phone '� Z (ef f
2. Address
3. Property Owner if Different than 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
IndustryOther
b) Number of people
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 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 apprrovedl Yes No
9.,a) Property Dimensions
b) Land area designated to building sit _
c) Sewage Disposal Contractor AQ'►��-rP _� f' ,,d'r`�'�_LeX1 6� 7;zf )e9.7z _f
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? OGt�
What"type? QDa_
This is to certify that the information is correct to the best knowledge. d c e d
? �J� '� r
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FO LIANCE WITH ALL STATE A (/CAL LAWSMP
Allow 5 days for processing
Directions to property:
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BENT 3
N 88° 03. 43" E dP NIP 313.48 TOTAL '
AXLE ♦ PIP
28133 321.42 TOTAL 40.09 39.91 132.13 192.06 TOTAL
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FOSTER ti0h
480 AREA = 1.516 AC. O
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( INCLUDES S.R. 1620 R/�N 1 + eo N
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418.06 l
DAVIE COUNTY HEALTH DEPARTMENT
-4 Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name � �' Date � �!
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position �,�_ S S S
C ) PS PS PS
H� 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
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS
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 Title Date
SITE DIAGRAM
. l
UCHD(6-82)