394 Oakland Avenue Lot 102. f � .,y. Fye, -- ,.... ... .....". ..,.... .. , ..... .a,e""cpr. r•.w -.... - - ..
DAVIE COUNTY i HEALTH DEPARTMENT
-IMPROVEMENTS PERMIT AND CERTIFICATE "OF COMPLETION
*NOTE: Issued in Compliance wltli G.S. of North,; Carolina Chapter 130 Article 13c
Sewage Treatment; and Dsposal Rules:�(.i 0 N++CAC 10A .1934-.1968) Permit Number
Name 1'��%r U/'o�cy� ;I' i 3`- 2 ?7 �
Date L
:Location G 5� Lv rST
Subdivision Name Qr7t'/sLtz Mhg�.✓f i Lot No. /67- Sec. or Block- No.
.Lot Size /OOX zoa ' House Mobile Home _4-- Business _ Speculation
No. Bedrooms i No. Baths No. in Family
Garbage -Disposal . I !YES ❑ NO. Ejj,
II Specifications for System:. opo ryv"�
Auto Dish Washer YES :❑ NO: ❑
Auto Wash Machine' !YES NO ❑ i I
Type Water Supply4A%1A�jA:�;li
This permit Void - if sewage system described below isl not installed within 36 months from date of issue.
I• � (r ; }.1 cry+
Improvements permit by L
'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; n' System Installed by 4 r�
a
L-54 r i
}� 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''re.gulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for anyl,given period of. time.
,1.
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. O. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE 3-2-87
• Timothy Ray good
Rt. 2, Box 451
.iocksville, NC 27028
L Permit 4648 1
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.
Permit 464£ 1$15.00
w REC -
!-'APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT"
Davie County Health Department
Environmental Health Section
P. 0. Boz 665
Y r
Mocksville, N.0 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 29S' 5J2216 5
1. Permit Requested By A�9V rio o� Business Phone 9`3 a o
2. Address /f -` -2 /fit lznA% rri,//-e .r/r• 2 ;'- -2 R
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-L�—Alter Repair
b) Privy tL`�Conventional Other Type
Ground Absorption
c) Sub-Division,2��2`15% Pc Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people e7Z
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 1 2e X 2 -0 --
Bed
oBed Rooms— Bath Rooms4ZDen 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 urinals
lavatory showers
dishwasher
sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions %o O X �,' a o '
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? A10
What type?
This is to certify that the information is correct to the best of my knowledge.
O
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
ti
C0 q w 4
DCHD (6.82)
c 2 pa,z �.
0
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
y,t4A# to
a
Name F; ry1 C) I t \/ A Y W V o A Date :I — -� b o b
Address ax e Lot Size D ° 1 a -o O
�er.TnRc eRFA i ARl FA 9 AREA 3 ARFA 4
Topography/ Landscape PositionS
P
PS
S
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
(
S
PS
S
PS
S
PS
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
S
PS
S
PS
U
U
U
Soil Depth (inches)
S
S
PS
S
PS
U
U
U
i) Soil Drainage: Internal
pS
S
PS
U
S
PS
U
External
PS
FS
S
PS
U
S
PS
U
i) Restrictive Horizons
------------
Available Space
PS
PS
S
PS
U
S
PS
U
I) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
!) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE QPS Provisionally Suitable
Described by� Title Date —
SITE DIAGRAM
DCHD (6-82)