1095 Ridge Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION P
*NOTE:Issued in Compliance With Article II of G.S.Chapter 130a --
Sanitary Sewage Systems Permit Number
Name 19�'19r, _1& /�' c�.�� �,� �f Date N2 5903
Location � '` �f f'F ✓ li � fy�, �f r r :_% /�� - i%i/." J ���r
i
Subdivision Name Lot No. Sec. or Block No. j
k
Lot Size House �r3 Mobile Home _ Business 'Speculation" �
No. Bedrooms _ No. Baths No. in Family
Garbage Disposal YES ❑ NO pr Specifications for System:
Auto Dish Washer YES NO ❑ ,,r �,
Auto Wash Machine YES j NO 6 'a'
Type Water Supply
*This permit Void if sewage system described below is not instalIV withiR5 years from date of issue.
This permit is subject to revocation if site plans or the intended-Use ha0ge.
N
1=
,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: 704-634-5985.
Final Installation Diagram: System Installed by
S S
Certificate of Completion ���"� ` Date �� _ a, - y U
*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
� Davie County Health Department D MPR Q
�,, Environmental Health Section C wE
�D P. 0. Box 665 R�
10;000,(A
0� Mockoville, NC 27028 � .
1 . Application/Permit Requested By L �✓ ��,
Mailing Address �yl. I ( x ;313 �nc_�Ssc�i��<• l�• Z 7(��2 FS
Home Phone qq-') - J 7cW Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above
. 4. Application/Permit For: lC) General Evaluation VS/Tank Installation,_
S. System to Serve: House Mobile Home D Business
Industry
XOther Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Z Basement/Plumbing
No. of Bathrooms ! Basement/No Plumbing
Washing Machine Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served No. of Sinks
No. of Commodes No. of Urinals
No. of Lavatories No. of Water Coolers
No. of Showers
8. Type of water supply: Q Public Private Q Community
9. Property Dimensions
10 Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes No
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify that the information provided is correct to trice
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
Date Signature
7/-o S71ro�crl'S EXXo+i T4kr a /elf7- orl./' 746
Directions //to Property : r
�o � ,1.Ci/pf cY a art '{b l ri r •+C o 't ��i� Y ���i�
DCHD (10-89)
-� DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 11;,*A 5- Date 3-Q�
Address Lot Size tJ�C
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay) P
�' `–(J U
3) Soil Structure (12-36 in.) S SS S
Clayey Soils � (A
U U
4) Soil Depth (inches) S
P (�LJ PS
5) Soil Drainage: Internal S S
PS (� (PS
External S U
_ S
6) Restrictive Horizons /
7) Available Space
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
Recommendations/Comments:
Described by Z( Title . � Date
SITE DIAGRAM
Y
DCHD(6-82)