376 Oakland Avenue Lot 105DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE.-OF COMPLETION.,
'NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage`Treafine�nt and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number'
Name N` �5'' ' �"I�� a'��O?e' s'� Date xl�10 A7
Location
.. �'�.' t ,,.t .._ �I•S�t'\ ��F":S*a.F.5:�1 l�� :'7.y 1..-i.w. � y<�•�v� :l C'f�. ��•*�'�•`�a
• . �.; . � �\VJ� `..� !L:�a' � ti r`•� �+� � •:`�'�.r . — 1.� ti :,,. '.��..- cI`+.. C�".SS�,. •�, q�,3' rye �'
Subdivision Name{''�► Ls _,�� [. :4 .._' � Lot No. ()4� Sec. or Block No.
Lot Size' House ' '` Mobile Home Business Speculation
No.'Bedrooms ' �1No. Bats No. in Family
h.
Garbage Disposal YES ❑ NO [ ° Specifications pecifications for System
AutDish Washer YES ❑ ` NO% ),0-
o
'Auto Wash. Machine YES jV. NO -p.
TYPe Water Supply
*This permit Void_ if.sewage system described below is not, installedwithin 36 months from date of issue.
Improvements permit by 'I �.r� . •'.
*Contact a• representative of the Davie County Health Department for final inspection of this system between 8:30-..
9:30 A.M.. or 1:00-1:30IP.M., on day of completion. Telephone Number: 704-634-5985.
Final_ Installation D,iagra II: , System Installed by,
Certificate of Completion
The signing, of this.c'ertificate shall:indicate that the system described,above has .been installed:`in'compliance with.. -
the standards set forth in:the above regulation, but shal..in NO way be taken as a' dararitee.that the.system•will function
satisfactorily for ahy given period of time
01
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department ��
Environmental Health Section tt J
P. 0. Box 665 �1E i``
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.`—
1. Permit Requested By
'
2. Address /� d ���L�
3. Property Owner if Different than Above
Address
Home Phone
Business Phone & J
4. Permit To: a) Install r Alter Repair
b) Privy Conventional v'- Other Type
Ground Absorption
c) Sub -Division
�-Z��ll o��48ec. Lot No. / Lf S
5. System used to serve what type facility: House Mobile Home — Business
Industry Other
b) Number of people .21-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions ::7 4 CL 41f"'`� %_,
Bed Rooms —a 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 lwater-using fixtures:
commodes / ✓ urinals
lavatory ''` showers l
dishwasher sinks
8 ) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
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? /-;/ D
14 X "�-v-
garbage disposal
washing machine
What type?
This is to certify that the information is correct to the best of my knowledge.
%-ter- '5_7 HA2 e �
Date 46wner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
_1�vl � A--
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
_.......SOIL/SITE-EVALUAT4ON
Name Date
Address Lot Size / Q U G
FAr.TnRC
AR4 1 1 AR�2 1 AREA 3 ARFA 4
Topography/ Landscape Position
S
PS
S
PS
(P�
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)PS
S
PS
S
PS
U
U
U
I) Soil Structure (12-36 in.)�
Clayey Soils
PS
*U
S
PS
U
S
PS
U
U
Soil Depth (inches)
f:ks
S
PS
S
PS
U
U
U
U
i) Soil Drainage: Internal
pS
� PS's
S
PS
U
S
PS
U
ExternalS
PS
Q�)
S
S
PS
U
177-
U
U
U
1) Restrictive Horizons
Available Space
4
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
S
S
PS
S
PS
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title
SITE DIAGRAM
DCHD (6-82)
Date ^_
/ 4