457 Madison Road Lot 9yy �`4 fes+ DAVIE COUNTY HEALTH DEPARTMENT 9" 6
" IMPROVEMENTS PERMIT AND. CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article 11 of G.S. Chapter 130a
anitary Sewage Systems Permit Number
Name /rA Date N2
�/ �� / f% 6529
Location �f%///%' �PY V 6i%� 5lJ/,IIL/.�/' 1Si!%p � vPJn/�,/:!/�ZIJ� PSiJ d)t
Mr:
Subdivision. Name J 70n S/ /7 r00 iC Lot Nb4/ 70__ Sec. or Block No.
r
Lot Size ISOIf>'?Z) House —Pl*� Mobile Home __ Business Speculation
..No. Bedrooms No. Bathsc%�A No. in Family
Garbage Disposal' AYES ❑ NO pf Specifications for Sys em:
Auto Dish Washer. YES,E NO ❑®����
Auto Wash Ma:hine YES,-Ltj NO ❑ q
Type Water Supply 140
*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.
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 F \' �,,.f M t \\,Z R
r -
Certificate of Completion \ —.Date'):) )3 -
'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 lime.
S,
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section.
P. O. Box 665
Mocksville, NC 27028
1. Application/Permit Requested By J�rj'd 1 kA r\
Mailing Address [l!C / d N //X e -(O T
Home Phone �: — Business Phone �-
2. Name on Permit if Different than Above
3. Application/Permit for:
❑ General Evaluation
Septic Tank Installation
4. System to Serve: OZ House ❑ Mobile Home ❑ Place of Public Assembly
❑ Business ❑ Industry ❑ Other ❑ Unknown &
5. If house, mobile home: Subdivision 400� Section ( Lot # 1.0—' '
Svr>`�o P-
No. of People
No. of Bedrooms
No. of Bathrooms 2-
Dwelling Dimensions A:4;- F 5 ?, X �%
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 _
7. Type of water supply: ublic ❑ Private
8. Property Dimensions - / mIrad D Sewage Disposal Contractor
❑ Basement/Plumbing
❑ Basement/No Plumbing
,a Washing Machine
ER Dishwasher
❑ Garbage Disposal
9. Do you anticipate additions/expansion of the facility this sytem is intended to serve? ❑ Yes 2 -60
--
If vwq_ what tvna?
❑ Community
'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:
cti�d
This is to certify that the information provided is correct to the best of my knowledge, and I understand I am responsible for all charges
incurred from this application. e
DATE
FOR SITE EVALUATION TO BE
MUST CHECKONE: ❑ 1. 1 OWN the property.
If you checked Box #2, the rest of this form MUST be completed by
I hereby give consent to the authorized representative of the Davide
property located in Davi ounty and owned by
to conduct all testing pro edures as necessary to determine said si
and disposal system.
9— /o /9/
DATE
DCHD (12-90)
ABOVE DESCRIBED PROPERTY
❑ 2. 1 DO NOT OWN the property.
owner or a person authorized by the owner:
ty Health Department to enter upon above described
a
sewage treatment
DAVIE COUNTY HEALTH DEPARTMENT 1
Environmental Health Section,
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION I� 4 q
Name �•�•. c� ca Date I - u 1
Address oR-v Lot Size ld'D
FACTORS ARFA i ARFA 9 ARFA 3 APPA A
1) Topography/ Landscape Position
(P
Z
S
S
PS
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,ts
Loamy, Clayey, (note 2:1 Clay)
PS
S
PS
S
PS
U
U
3) Soil Structure (12-36 in.)
Clayey Soilspg
S
PS
S
PS
S
PS
U
U
I) Soil Depth (inches)
GC
9)
S
S
PS
PS
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
S
PS
U
U
External
Ca7
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
PS
S
PS
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
1P S
Al 5-,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: ; H
Described bye \\S C• Title��1��� ti�� Date li 13
SITE DIAGRAM
0z
1�t
UCMD (6-e2)
0D
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
A
Date `
r
1
): S
PS
Address
PS
Lot Size
U
U
FACTORS ARFA I ARFA 9 ARFA 3 AGFA A
1j Topography/ Landscape Position
A
0
S
S
): S
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PS
S
PS
S
PS -
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
(pS%
(PSJ
S
PS
S
PS
U
U
1) Soil Depth (inches)
S
S
S
PSS
S
PS
PS
U
U
U
U
i) Soil Drainage: Internal
fpS/
S
PS
S
PS
U
U
External
t a/
S
S
PS
S
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
SS
S
PS
S
PS
U
U
U
U
i) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
�S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by 2. Title Date 3 --6
SITE DIAGRAM
D4/
a
CDU
DCHD (6-82)
021