512 Deadmon Rd Lot 5P1. •, //
DAVIE COUNTY HEALTH DEPARTMENT 3 ��
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTJ* Issued in Compliance With Article II of G.S. Chapter 130a
anitary Sewage Systems i>>y�r ��' �ir�.. i/f Permit Number
N
Name 7407 r"✓'r��� xrr;>r Date �1� 1f� 0
Location1
Subdivision Name —Lot No. -�V Sec. or Block No.
Lot Size/ir,.1 House v�' Mobile Home _T Business _— Industry
No. Bedrooms No. Baths T -� No. in Family Public Assembly Other
,_Garbage Disposal YES ❑ NO E'r Specifications for System:
Auto Dish Washer YES NO E] e
Auto Wash Ma thine YES NO p ,
Type Water Supply
*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.
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.,
1:00-1:30 P.M. or 4:30-5:00 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram:
System Installed by�'�y --
1-{G
ry
7-
a J. L) f o 4
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LUkiJ
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.
1. Application/Permit
Mailing Address
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, NC 27028
By
2. Name on Permit if Different than Above
X 70 7 '�?' Home Phone�� 1Ro %C�I
Business Phone
3. Application for: ❑ General Evaluation Cr Septic Tank Installation Permit
4. System to Serve: Zr/House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown
5. If house, mobile home: Subdivision l/ Section Lot #
❑ Basement/Plumbing
No. of People
No. of Bedrooms 3
No. of Bathrooms 4
Dwelling Dimensions ��Zd
6. If business, industry, place of public assembly, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Sinks
No. of Urinals
No. of Water Coolers
No. of Showers Water Usage Figures
❑Basement/No Plumbing
al
washing Machine
Dishwasher
❑ Garbage Disposal
7. Type of water supply: (T_'� Public ❑ Private ❑ Community
8. Property Dimensions ,J All Sewage Disposal Contractor /�*P✓�
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ 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.
Directions to Property:
a/ sU�t� ��o� WV �� �,'� S
7Q � kc, do f
This is to certify that the information provided is correct to the best of my
incurred from this application.
—� DATE
and
SIGNATURE
I am responsible for all charges
CONSENT FOR SITE EVALUATION TO BED NE _ON ABOVE DESCRIBED PROPERTY
MUST CHECK ONE: fl 1. 1 OWN the property. ❑ 2. 1 DO NOT OWN the property.
If you checked Box #2, the rest of this form MUST be completed by the owner or a person authorized by the owner:
I hereby give consent to the authorized representative of the Davie County Health Department to enter upon above described
property located in Davie County and owned by
to conduct all testing procedures as necessary to determine said site's suitability for a ground absorption sewage treatment
and disposal system.
DATE SIGNATURE
DCHD (1/93)
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Ll= Dn'1 a�� Business Phone S12/m E
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install If 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 l7,,p CX AP /
b) Number of people
6. aj If house or mobile home, state size of home and number of rooms.
House Dimensions
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 I
lavatory
dishwasher
urinal
showers
sinks
garbage disposal
washing machine f
8. a) Type water supply: Public k"__ Private Community
b) Has the water supply system been approved? Yes�No
9. a) Property Dimensions 1 O XZj- o
b) Land area designated to buildi site /q /t _
c) Sewage Disposal Contractor A V r (= S 4 O /"If. /
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? All"°
What type?
This is to certify that the information is c rect 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:
O�
�/�
�9 5
OCHO (8.82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
f� Mocksville, N.C. 27028
L• SOIL/SITE EVALUATION
Name --TDate
Address Lot Size 60 k 400
FArTr1RS
A11EZ2 J AREA 3 ARFA 4
Topography/ Landscape Position
C4--)
PS
PS
U
U
U
U
�) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
c=Ra=
S
PS
S
PS
U
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils'
S
---,.5
S
PS
U
S
PS
U
U
G) Soil Depth (inches)
S
S
S
PS
U
PS
U
Soil Drainage: Internal
S
S
S
PS
S
PS
External
PS
PS
S
PS
U
S
PS
U
�) Restrictive Horizons
Available Space
S
PS
S
PS
U
U
U
U
{) Other (Specify)
S
PSS
S
S
PS
S
PS
U
U
U
1) Site Classification
U—UNSUITABLE
Recomr,nendations/Comments:
a3
S—SUITABLE PS—Provisionally Suitable
Described by �- Title Date
SITE DIAGRAM -- —
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DCHD (6-82)
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