274 Riverdale Rd (2) DAVIE ,COUNTY HEALTH DEPARTMENT ,3 CJ V
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
T �*NOTEJOued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems 'Permit Number
Name A <I - til , r nate —f �<<'° ; N2 5930
Location
710
Subdivision Name Lot No. — Sec. or Block No.
Lot Size House " Mobile Home _ Business Speculation
No. Bedrooms _ No° Baths l No. in Family
Garbage Disposal YES ❑ NOj'✓ Specifications for System:
Auto pish Washer YES NO ❑ / ;! � '
Auto Wash Machine YES [� NO ❑ `� � rs
Type Water Supply t _
*This permit Void if sewage system described below isnot i stalled within 5 years from date of issue.
This permit is subject to revocation if site plans or t 6 in n dd use change.
r
f
GA): Imp ovemer}ts 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 NSmber:,704-634-5985.
Final Installation Diagram: System Installed by
QO
' . b C
Certificate of Completion �� �� Date
"The signing of this certificate shall indicate that the system described above has been i �atalled i. compliance with
the standards set forth in the above regulation, but shall in NO way be taken as a guarantee the s stem will function
satisfactorily for any given period of time. ��
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. sox 665 RECEIVED MAR 2 6 1990
Mockoville, NC 27028
1 . Application/Permit Requested By Urh 4,n,�
Mailing AddressU _fig o �942�e-_kC'i��/� C.� .
Home Phone M_ 2 �2 U Business Phone
2. Name on Permit if Different- than Above
3. Property Owner if Different than Above
4. Application/Permit For: lC) General Evaluation S/Tank Installation
S. System to Serve: ['House -1 Mobile Home C] Business
L Industry u Other 0 Unknown
6. If house, mobile home: Subdivision Sec. Lot#
No. of People Dwelling Dimensions
No. of Bedrooms Basement/Plumbing
No. of Bathrooms I Basement/No Plumbing
8-1Aashing Machine (J' Dishwasher C) Garbage Disposai
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: Public Private 'Community
9. Property Dimensions ex(!'__5
10. Sewage Disposal Contractor
11 . Do you anticipate additions/expansions of the facility this system is
intended to serve? 0 Yes 2—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 the
best of. my knowledge; and I understand I am responsible for all
charges incurred from this application.
011/ 9U Alzi.
Date Si,+gnature
Directions to Property :
DCHD (10-89)
Y �
DAVIE COUNTY.HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
/ SOIL/SITE EVALUATION
Name
r Date
Address Lot Size gldj�
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S_
0 PS
U U
2) Soil Texture (12-36 in.) Sandy, _
Loamy, Clayey, (note 2:1 Clay) PS) P 'S
3) Soil Structure (12-36 in.) S,
Clayey Soils `fT
U
4) Soil Depth (inches)
P '�TJ CTJ -�P
5) Soil Drainage: Internal
External
P
U U U
6) Restrictive Horizons
7) Available Space v' �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
�� Title ��"'� Date
SITE DIAGRAM
DCHD(6-82)