467 Madison Road Lot 10vc
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance With Article I I of G.S. Chapter 130a
anitary Sewage Systems �//� Permit Number
Name��-� /F d,(Y44 7 Date Z1Q3'9/ N0 6258
Location Al
Subdivision Name r�/��a'•Lp Lot No. Sec. or Block No. /
Lot Size House Mobile Home _ Business Speculation
t 1
No. Bedrooms .S No. Baths No. in Family
Garbage Disposal YES ❑ NO p' Specifications for, System;
X
Auto Dish Washer YES NO ❑ 000 ter,! Y
Auto Wash Machine YES [$_ NO ❑ cr
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 Ti or t e in use change.
*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
T1s
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.
APPLICATION FOR SITE EVALUATION/.IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. o. Box 665 RECEIVED JAN 10 fes.
Mockoville, NC 27028 .
1. Application/Permit Requested By �i Fid (3OuS( Rl¢C'TICIJ �� �Ci_
Mailing Address Vow --e .g 226)k Qk-1 KXWGOILLE
Home Phone 22R—NO-7 Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Above ZLQ I fiRlr
4. Application/Permit For: 0 General Evaluation S/Tank Installation
S. System to
Serve: House "I Mobile
Home
0
Business
Industry Other
Unknown
6. If house,
mobile homes Subdivision
Sec.
Lot#
No. of People Dwelling Dimensions.
No. of Bedrooms Basement/Plumbing
No. of Bathrooms_ ` Basement/No Plumbing
Washing Machineishwasher Garbage Disposal
7. If business, industry, other: Specify type
No. of People.Served
No. of Commodes _
No. of Lavatories _
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
8. Type of water supply: Public Private n Community
9. Property Dimensions X00 k OU
10. Sewage Disposal Contractor
11. Do you anticipate additions/e pansions of the facility this system 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.
This is to certify that the information provided is correct to the
best of my knowledge, and i understand lam responsible for all
char es incurred from this application.
o 1
-90 o 'Ou� �VQ.A /
Date Signature
01 (v U RT �i
Directions to Property:
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORS AREA 1 AREA 2 AREA 3 ARFA d
1) Topography/ Landscape Position
6)
8)
9)
l9
PS
U
(9)
S
U
S
PS
U
S
PS
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PS
U
S
PS
U
3) Soil Structure (12-36 In.)
Clayey Soils
S
S
PS
U
S
PS
U
1) Soil Depth (inches)
PS
U
PS
U
S
PS
U
S
PS
U
5) Soil Drainage: Internal
U
S
PS
U
S
PS
U
External
ySW
P
U
S
PS
U
S
PS
U
Restrictive Horizons
Available Space
®
U
-45)
U
PS
U
Other
PS
U
(Specify)
S
PS
U
S
PS
U
S
PS
U
S
PS
U
Site Classification
f
-
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: �� y 4i2'
Described byy •� C Title Date
SITE DIAGRAM
4.
04,
ON
dao
10 f/t/ .