388 Oakland Avenue Lot 103;i. y-• 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 10A .1934-.1968) " Permlt Number.'%
Name 1��� �ti o A 1�.;� c7;��r. Date ' ` 1 1 C�� a� A 0 A
Location __"� -<<� !� ,:�' 6��,���. �•.
, h —
c1 .
Subdivision Name A I�A �� � o �� Lot No. 0 Sec. or Block No.
- !1, �X
Lot Size
House;' Mobile Home'Business-SVeeula�on`
lNo.,.Baths"�.
'
No. Bedrooms _No" in Family______.'•
Garbage Disposal YES ��❑ Nd
Specifications for System:
Auto Dish Washer . , YES ❑ NO 00U •.��� �� � _ � � �
Auto Wash Machine a YES NO ❑
Type: Water Supply li '.-F_,w 4, pU `. )('
-f
`This permit Void if sewage system described below is not installed within 36 months from date of. issue.
0"
�. Improvements permit- by `, •.
r .4•
`Contact a represeKtative 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 bv���
i -
y 61 - h
?' � '
or
7.
id
n ! Certificate o Completio Date " C1
'The signing of this.ce'rtificate 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
y I • APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT 1
Davie County Health Department 10
Environmental Health SectionLAc
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requ
2. Address —
Home Phone y?�_ 7/0y /
Business Phone
3. Property Owner if Different th
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division ?Q16AC Sec. Lot !N�o M
5. System used to serve what type facility: ouse Mobile Horn Business
Industry Other
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions a- ��y'" `' •
Bed Rooms "'2 Bath Rooms l Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hou
7. Number and type of water -using fixtures:
commodes
lavatory —
dishwasher
urinals
showers
sinks /
8. a) Type water supply: Public Private Community
b) Has the water supply system beenproved? Yes No
9. a) Property Dimensions �5`x 65/ X 'goo '906, X �C
b) Land area designated to building site
c) Sewage Disposal Contractor
Z
garbage disposal
washing machine
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information is co rre tom the best of my knowledge..
May, /�� / qe7.�iGr.�=/�
Date Owner S' nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
I
Address
ff
GA r -Tr) P C
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA\i J
Date
Lot Size Q `y,a�
AR;:K 9' ) AREAl3 1 ARFA 4
Topography/ Landscape Position
46PP`' 7
S
(5a
S
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
SP
S
��
�T'
S
S
PS
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
,S�
[ PS7
S
t'PSn
S
PS
Soil Depth (inches)di-S,
�
S
PS
U
U
U
U
�) Soil Drainage: Internal
p
&
S
PS
U
U
U
External
PS
S
PS
U
U
U
U
i) Restrictive Horizons
Available Space
PSS
�'
P
U
S
PS
U
U
S) Other (Specify)
S
PS
S
PS
S
`PS
S
PS
U
U
1) Site Classification
c C
v
s
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS `Provhsionaliy Suitable
Described by Title
SITE DIAGRAM
DCHD (6-82)