1704 Yadkin Valley Rd DAVIE COUNTY HEALTH DEPARTMENT
_ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION,-],' 00
-NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date N2tij"a'
Location ...
- [v
;�Y� �)V.f-.-�.3 h-� �.),'�t'.a �4; •3;�• , �.1\?'J{•wY�.I__
Subdivision Name \ \\\Y Lot No. Sec. or Block No.
Lot Sizes House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES;O NO Specifications for System:
Auto Dish Washer` YES �i NO p - �.
Auto Wash Machine YES p' NO .C]
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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 .Z R1��
A,
Certificate of Completion Date
*The signing of this gertificate,sh'all indicate that the systerd 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
r Davie County Health Department I Q
Environmental Health Section
Moc svi�lle, N.C. 7028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 999- 31la
1. Permit Req u sted By Larrg r, � i o( Ga'I e- Business Phone -'76$-6411 rYf�9S
2. Address Ko"te- & AAUCLAce , �JLyo(o
3, Property Owner if Different than Above Vada S. Ri dd l e_
Address P_o,,+e to AokUcxnce , fQQ_ allooG
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 a x 40,
Bed Rooms
Bath Rooms -Wa-- '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 3 urinals garbage disposal
lavatory 5 showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ( CLC'r e__
b) Land area designated to building site _
c) Sewage Disposal Contractor PC,-LL1 lei I lard _ r
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? No
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
ad/G'n Oo-Ile, 41,1 1, W �O 01d enf-►'an�)
OL P pro x• ry►cLfe l y 'Iz m•Ie- o rN
J a s+
DL,_kc Power- we rs .
DCHD(6.82)
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• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
\ SOIL/SITE EVALUATION
Name lr�'A`g �u � e Date
Address .,� AQ Lot Size `
FACTORS AREP1 AR A 2 AR A 3 AREA 4
1) Topography/Landscape Position S S
P (::Pb PS
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS4 U
PS
1 U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U
4) Soil Depth (inches) S S
PS PS � FS
U U lJ.
5) Soil Drainage: Internal S S
PS P - PS
U U U U : --
External S S
Pg P ( PS
U
U
6) Restrictive Horizons
7) Available Space S S
PSPS
U U U
8) Other (Specify) S S S S
PS PS PS
U U
9) Site Classification 5 1 1 (
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(6-82)