233 Yadkin Valley Rd Lot 3'+ Lt-..._.. ,`.w-� )�� - •.:-v ,. :-ice ... .aL.r S s .+ -
DAVIE COUNTY HEALTH DEPARTMENT a�
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ^,
NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c '
Sewage Treatrr ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ,/�l� ir-', `�� .,/ � �s� �7. �;%_ ,/, Date _ ��/% � Nr
�
Location
Subdivision Name r Lot No. 1-7_ _ Sec. or Block No.
Lot Size House 4,-� Mobile Home _ Business Speculation
No. Bedrooms No. Baths �� No. in Family
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES NO C] T
Auto Wash Machine YES NO C ���U
Type Water Supply
�a &-1X3Xia,/
This permit Void if sewage system described below is not installed within 36 months from date of issue. il
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.
J /
Final Installation Diagram: System Installed by
1. P
Certificate of Completion �'f ,,�� Date %jos
"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.
oC'Y
T
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.
J /
Final Installation Diagram: System Installed by
1. P
Certificate of Completion �'f ,,�� Date %jos
"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
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone "--Z- 7E 7 c?
1. Permit Requested By �U✓��<2go� sic/s�7�g Business Phone '7'7R- 7R7!2
2. Address 2r"�E; /30K 367 /1%ocKsNrc-cE a7a29
3. Property Owner if Different than Above
Address
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
IndustryOther
b) Number of peop
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 4 Bath Rooms 3 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
lavatory —
dishwasher
urinals
showers
sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 3 A cA�E
b) Land area designated to building site
c) Sewage Disposal Contractor
garbage disposal
washing machine
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is gorreci 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 pro erty:
DCHD (6-82)
Name_
Address
aed-1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date 4/XAr-y
Lot Size -c-�e-f-
FACTORS ARFA 1 ARFA 9 ARFA 3 ARFA d
1) Topography/ Landscape Position
CS
PS
PS
S
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
r?�j
S
PS
S
Ems'
�
U
U
3) Soil Structure (12-36 in.)j
Clayey Soils
L C
P
P
S
`PS
U
U
U
1) Soil Depth (inches)
�
lr?'
PS
S
S
U
U
U
i) Soil Drainage: Internal
P
U
U
_�
U
External
S
S
S
OPPU
i) Restrictive Horizons
Available Space
PS
S
PS
S
PS
CS
PS
U
U
U
U
I) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
1) Site Classification
/�—U
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
l7
Described by Title /1� Date
SITE DIAGRAM
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DCHD (6-82)
X3
U.
DAVIE COUNTY HEALTH DEPARTMENT U��I{pwj
Environmental Health Section
P. 0. Box 665 Lit '3
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Apbd #4 rr1- ,CSE'*✓ oF":1/f - C•% �4�. y-4--64,u1� Bi?.w.✓ Date Z -J 0 "Pf"
Address �• °'�� 7yp Lot Size 3• " Auur
At 2-7-102-
FArTnRS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/ Landscape Position
'ZP
S
S
PS
PS
PS
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
®
��
PS
PS
U
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
—�>
PS
PS
U
U
U
U
i) Soil Depth (inches)
C
C9
S
S
�PS
�8 US)�
U
PS
U
PS
U
i) Soil Drainage: Internal
S
S
S
S
<niSiP>
PS
PS
U
U
U
U
External
S
S
S
S
�
PS
PS
U
U
U
U
P) Restrictive Horizons
Available Spacem
PPS
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
LIS
P --
U -UNSUITABLE S -SUITABLE e - -F?.-,— itahle7
Recommendations/ Comments: S'.4[4- a-1 � &e'l" � Of
tea--
/Xa Q -/ !V � • '-e.- z .
Described by Q ma Title Date 2 -10
SITE DIAGRAM 4 a livow v 41leh ��o S2-
DCHD (6-82)
'+ Lr-..._.. ,`.w-..y.� •.:-v ..:-ice ....aL.r S ,/ -
DAVIE COUNTY HEALTH DEPARTMENT a�
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION ^,
NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatrr ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name,/�l�ir-',``��.,/ � �s� �7. �;%_ ,/,Date _��/ � N2 55 r
�
Location �J ' , �7�Vif�
Subdivision Name 1./��r��� �`�� fy%�,i r Lot No. - _ _ Sec. or Block No.
Lot Size r2r 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 p Me
Type Water Supply _—
This permit Void if sewage system described below is not installed within 36 months from date of issue.
I
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.
J /
Final Installation Diagram: System Installed by
iA 19 �.
F
Certificate of Completion �'f ,, Date %jos
"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
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone "--Z— 7 7 1
1. Permit Requested By �U✓��<2go� sic/s�7�g Business Phone 7R7!2
2. Address 2 7— 'E; /vo is 3 6 7 /77 o c K sN r c-c E a 7 a 2 9-
3.
3. Property Owner if Different than Above
Address
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
IndustryOther
b) Number of people
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 4 Bath Rooms 3 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 garbage disposal
lavatory 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 3 4 cA�E
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?
What type?
This is to certify that the information is gorreci 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 pro erty:
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
l SOIL/SITE EVALUATION
Name— i1i���'��a/ Date
Address Lot Size c �G'
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position CT) S
PS PS S
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) P PS Ems'
U U
3) Soil Structure (12-36 in.) / S
Clayey Soils L C P P `PS
U U U
4) Soil Depth (inches) � S S
lr?' PS
U U U
5) Soil Drainage: Internal p
P
U U U
External S S S
U
6) Restrictive Horizons
7) Available Space S S CS
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U 52—U U U
9) Site Classification _ f-
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
l7
Described by Title /1� Date
SITE DIAGRAM
yl
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT UA)I{ R�''"�
Environmental Health Section
P. 0. Box 665 Lit '3
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Apbd #4 rr1:�/�- ,C�E'�✓ �j:I/f .C•% ✓ Date Z-J "Pf�'
Address Lot Size -3 r
At 2-71,02-
FACTORS
Bio2FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position ZP 41f S'-> S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ® �� PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils —�> PS PS
U U U U
4) Soil Depth (inches) C C9 S S
� PS PS PS
�8 US )� U U U
5) Soil Drainage: Internal S S S S
PS PS
U U U U
External S S S S
� PS PS
U U U U
6) Restrictive Horizons
7) Available Space m S S
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 — i
Recommendations/Comments: t-4[4— 4 &e'l" Of
tea--
!�� Q / !V ' z� Ael , f/ DSL
Described by Q ma Title Date 2-10
SITE DIAGRAM
3uo.g61
1
�D ROAD a�D
300.09
DCHD(6-82)