P5796 Scenic Dr r b
DAVIE COUNTY HEALTH DEPARTMENT I60. 6
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
/.'3 o I
*NOTP-:Issued in Compliance With Article II of G.S.Chapter 130a
Sanitary Sewage Systems Permit Number
-� - ` 5796
Name �\) �. � �� � .���.. � �, �a _,,;�. Date --, t•, f i N 0,
Location �.. .. , .
Subdivision'Name Lot No. —_ Sec. or Block No.
Lot Size House Mobile Home —�— Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO R/ Specifications for System-
Auto,-Dish Washer YES ❑ NO p/
Auto Wash Machine YES [/ NO ❑
Type Water Supply * ,t� `a-. _
*This permit Void if sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
1
)o o'
�0
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.
Final Installation Diagram: System Installed by
t
�ry —rte-
CT
44
a _
� o
q
V
Certificate of Completion Date v 7 7()
"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 ,gyp
Environmental Health Section N ^�
R 0. Box 665
Mocksville, N.C. 27028 RGC
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone W( Z-- 7 cP//
1. Permit Rted B ► v e w Business Phone
e es
2. Address 90 k be k-5 (JI i t ir- Z -76
3. Property Owner if Different than Above 465.5''e F 6 Poky
Address
4. Permit To: a) Install v 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 Homey Business
Industry Other
b) Number of people Z
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions /Z- X S:
Bed Rooms 2 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 No garbage disposal /Y 2.
lavatory showers washing machine
dishwasher sinks ' f
8. a) Type water supply: Public // Private,-Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions
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? Ado
What type?
R
This is to certify that the information is correct to the best of my knowledge.
y
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
C f1i/F.vr
4 l5vic�G TK i%r
/1 {TOti•'f�
�J F/.�/s wh��� •
?vim.'/�v- w•'// G�
�;-_•)' v p. z- !s-- y
+ *NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
j to revocation, if site. plans or the intended use change.
Effective_October 1, 1989. _ _ _-
t =?!
DCHD(6-82)
Z-''._` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date
Address Lot Size
4�
FACTORS ARVA l AEA 2 A CEA A
3
1) Topography/Landscape Position S
< P PS
U U U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
U
3) Soil Structure (12-36 in.) S
Clayey Soils PS S PS
U U
4) Soil Depth (inches)
pS PS PS
5) Soil Drainage: Internal
pS PS PS
U U U
External
pS PS S
U U U
6) Restrictive Horizons
7) Available Space S
PS PS �PS� P
8) Other (Specify) S S S S
PS PS PS S
U
9) Site Classification -S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
- - c
Described by ` Title Date
SITE DIAGRAM
k
�o
DCHD(6.82)