P5189 Oakland Heights- ---w..4....-...►.•-,•.-•-•,.r.�.,v...-a.-.�.--�-...�.....,xr,�.:r�•o---... �„+. •,a-. ,.•-•.....,. rz� =-r,., .-.. _.;•4-- :is..;. ,a,L ,. ._ - r�
DAVIE COUNTY HEALTH DEPARTMENT 1r_
IMPROVEMENTS PERMIT AND CERTIFICATE OF' COMPLETION
*NOTE: Imed,in'Compliance with G.S. of North Carolina Chapter 130 Article 13c '
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968). Permit Number
��-`—; ' i) 3,�� -, c� ti
Name p' �9 '
�{ Date.
1
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Location ; ' � � 6:Y
Subdivision Name ;��� _ s . - �s ). 1� �_- Lot No. Sec. or Block No.
Lot Size h{. �r'c�o ` x 1
House � Mobile Home _ Business Speculation
• q.
No. Bedrooms No. Baths "" No in Family
• it �.. � •' '�
Garbage Disposal` YES ❑ k NO ; Specifications�or System:
Auto Dish Washer, 'I ❑ N0,3Q
Auto Wash Machine ;YESV►
q b , `' ; �c �"�� ` t► ,,: ��
i ANO,❑
' . 'L. :'i;7 way 'Gi'r •"� ...v (- � - �� J
Type Water' Supply--
*This permit Void if sewage, system described below is not .installed within 36 months from date of issue.
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Improvements permit by\
}Contact a representative of the Davie County Health-Department for final' inspection. of tffis system. between 8:30-
-.9:30 A:M. or 1:00-1:30-P.M. on day of completion:;, Telephone Number: 704-634-5985. 1
Final Installation Diagram: f r System Installed by w i
`.. ..
• i'r - � it
Certificate of Completion ` Date O �3
The signing of this certificate shall indicate that the system described above; has been. installed- in compliance With
tFie standards set forth in the above regulation, but. shalj' in NO way be taken as a guarantee�that the system will function
satisfactorily for any given, period.�,of time. � �_.
R
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT 4
Davie County Health Department MA�
Environmental Health Section R��5
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Re uested By 4 Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional�/_ Other Type
Ground bsorpti n
c) Sub -Division ����� ec. Lot No. 0� �e ✓"
5. System used to serve what type facility: 6use_4e:'_"Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �o?fid
Bed Rooms 3 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 water -using fixtures:
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
z
b) Has the water supply system been approved? Yes d No
9. a) Property Dimensions --/40 X Zoo
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?
What type?
This is to certify that the information is correct to the best of my knowledge.
�- 09Y
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions
to 1property:
(0 7' UV • ; %GIPS/ / o vt ! s aye
DCHD (6-82)
c
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size do 0 V
FAr;TORS ARFO AR D AR� eocn A
1) Topography/ Landscape Position
PS
S
S
S
1--JU
S
PS
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)P
PS
<PS
S
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
P
S�-�
PS
� P$
S
PS
U
1) Soil Depth (inches)S
PS
�
PS
U
U
U
i) Soil Drainage: Internal
S
U
U
S
PS
U
ExternalS
P
S
S
PS
U
U
i) Restrictive Horizons
Available Space
- -
PS
P
P
S
PS
U
1) Other (Specify)
S
PS
S
S.,
P
S
PS
U
i) Site Classification
U—UNSUITABLE S—SUITASCE PS rovisionally Suit
Recommendations/Comments:
Described by Title ��� �� Date ^ gA
SITE DIAGRAM
2)