371 Will Boone Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*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
iy !
Name J Q,rc�. Ca ,��. » Date �11 ` N2
162 .
Location
..v.:\'`I'�. . `'-'a�� _.".-:..+.7� ,^)`� ��t,.'i"�..7r• .�`C' '.:h?3^"S�'�' � _ l
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 ❑ Specifications for System:
Auto Dish Washer, YES ❑ NO ❑_
Auto Wash Machine YES ,❑ NO ❑ ;
Type Water. Supply
*This permit Void if sewage system described below is not installed within 3emonths from date of issue.
- 1
J
Improvements permit by �•-� r J -
*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
«
L1 J"
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.
PLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
t Davie County Health Department �.
' Environmental Health Section FIVE,� ®� y
P. 0. Box' 665 RF-(;
GMocksville, NC 27028
1 . Application/Permit Requested By
Mailing Address &/ �6
Home Phone �/} " �� � Business Phoned
2. Name on Permit if Different than Above Ck CV
3. Property Owner if Different than Above
4 . Application/Permit For : v General Evaluation S/Tank Installation
5 . System to Serve: rJ House aMobile Home Business
Industry Other Q Unknown
6 . If house, mobile home: Subdivision Sec. Lout
No. of People _ Dwelling Dimensions ( � z ) n
No. of Bedrooms 7Basement/Plumbing
No . of Bathrooms a-- Basement/No Plumbing
X Washing Machine ; Dishwasher (3 Garbage Dispusai
7 . If business, industry, other : Specify type 4J V _
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 : 71 Public fCT Private L� Communi.t.y
9 . Property Dimensions 1 V
10 . Sewage Disposal Contractor a-ao d _-_JC __-
1.1 . Do you anticipate additions/expans ons of the fac lity this system i.s
intended to serve? J 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 tree information provided is correct to the
best of my knowledge, and I understand I am responsible for all
charges incurred from this application .
1992 dt7/-,f
Date Signatu e
J,b-0Q/W0,1-) k- d b�) �e/ 41
Directions to Property :
1 n � -&I �J r rn dd ��
�y w q..ke L,,,A d .
DCHD (10-89)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Q) Date �- -
Address 5�'` "9` Lot Size
FACTORS ARE AR 2 AR 3 AREA 4
1) Topography/Landscape Position 4�3s) S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, SS
Loamy, Clayey, (note 2:1 Clay) PS —(f!!P� PS
U U
3) Soil Structure (12-36 in.) � S
Clayey Soils PS PS P PS
U
4) Soil Depth (inches) S
PS PS
U U
5) Soil Drainage: Internal S
PS PSPS:PS)
U
External S
PS PS PS
U U
6) Restrictive Horizons —
7) Available SpaceS S
S PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
c U
9) Site Classification S S
U—UNSUITABLE S— ITAB PS—Provisionally Suitable
Recommendations/Comments:
Described by - TitleDate `~
SITE DIAGRAM
112
UCHD(5-82)