P4117 Yadkin Valley Rd INFORMATION FOR SEPTIC SYSTEM REPAIR PERMIT ffjj
NAME ' PHONE NUMBER
ADDRESS SUBDIVISION NAME
��4d✓�..�. �'1� � 706
SUBDIVISION LOT #
DIRECTIONS TO SITE d Q �
All. Z�4,
41
DATE SEP IC SYSTEM INSTALLED L�
i
NAME SEPTIC SYSTEM ORIGINALLY INSTALLED UNDER ap/
SPECIFY PROBLEMS THAT ARE OCCURRING
DATE REQUESTED INFORMATION TAKEN BY
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 10A1 34-.ew Permit. Number
Name �> 'f., , r' � j r, of �.�/• �Di t1 ; tt 7
Location �c' ,;,. ;� , ;:'r,:•
of
Subdivision Name '� %� �� < (" S''�� Lot No. Sec. or Block No.
Lot Size House 1 Mobile Home _ Business Speculation
No. Bedrooms No. Baths 'EE No. in Family
Garbage Disposal YES T NO p Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES [j NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
L.7
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.
Final Installation Diagram: System Installed by
r--- I
cate-o'tompletion :-ff Date
*The signing of this certifikhe;;abbuD-cggu1ration,_but
hall-irrrdie fe that the system described above has been installed in compliance with
the standards set forth in shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size ,�/,��`
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) ( P,S� PS PS
l 'Tj U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils S7 UPS PS
4) Soil Depth (inches) �� S S
PS /C P5 3 PS PS
—>T U U
5) Soil Drainage: Internal SS S
PS 1p UPS PS
IJ
External S S S
PS PS
. U ct5 U U
6) Restrictive Horizons
7) Available Space � . S S
PS P5 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 1 PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(6=82) -
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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 PERM HAS BEEGN�ISSUED. /
Home Phone I I -5,36
1. Permit Req ested By � k&JI1A- ` Business Phone 7a Lf 456
2. Address • 7Q��o
3. Property Owner if Different than A v eY Q va avis L/ A Lei:
J�3 �
Address 01 W&DA'-l414.- 1XvxG2 •C-
4. Permit To: a) lnstallJZ�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 Dimensi ns 3a. X 11
Bed Rooms 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 3 urinals garbage disposal
lavatory. -3 showers washing machine
dishwasher sinks
8. a) Type water supply: Publict_Private Community
b) Has the water supply system been approved? Yes.No
9. a) Property Dimensions a-35� X 611 X Jag X 612
b) Land area designated to building site
c) Sewage Disposal Contractor Q 6`
U 11
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? r-�h44:Z5
What type? 7h� metd Will be •�`ini,:�" at a. take lime and Will
1 cl ud.Q andbaA rcen i a� baa.:- - mL
This is to certify that the information is correct to a best of my knowledge.
llliolSs ��;��
Date CiAvner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:T Yo 6 86 Ao r*h _ 24• en Yad kin valley U.
Vote
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DCHD(6-82)