306 Rollingwood Drive Lot 8 Section 3DAVIE COUNTY HEALTH DEPARTMENTg
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal. Rules (10 NCAC 10A .1934-.1968) Permit Number
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Name � On ,� b� -' '� i�r- ��i // Date N° 5703
Location
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Subdivision Name Jell %(iaz2 �%� Lot No. Sec. or Block No. -,
Lot Size House 1— Mobile Home _ Business Speculation
No. Bedrooms 1 , No. Baths r;2-0, No. in Family
Garbage Disposal YES .0 NO [ Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash MachineYES [ NO ❑ X41 000 'µ .�
_
Type Water Supply ' -- ��GO��X��'. ✓J <
*This permit Void if sewage system 4escribed•below is not installed within 36 months from date of issue. .
Improvements permit by — -' ` (:'J-11
*Contact a representative of the Davie County Healt\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
Certificate of Completion Date
f
'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.
1. Permit R
2. Address
3. Property
Address
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
RECEWSC AUG 21 1989
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone t7. 3 y -/-A �9 7/
Business Phone
4. Permit To: a) Install ✓Alter_ Repair
b) Privy— Conventional Other Type—
Ground Abs ption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: Housef 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 r7 o X,g O
Bed Rooms 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 a urinals
lavatory 3 showers
dishwashersinks %
8. a) Type water supply: Public Private—
rivate Corpmunity
b) Has the water supply system been approved? Yes— No_
9. a) Property Dimensions
b) Land area designated to building
garbage disposal
washing machine
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.
Date Owner Signature
WNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-e2)
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Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
/! k Date
Lot Size—
FACTORS ARFA 1 AREA 9 ARFA A ADCA A
1) Topography./ Landscape Position
(s
VS
PS
S
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,PS
Loamy, Clayey, (note 2:1 Clay)
--
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
S
®
S
S
S
(:57
U
U
1) Soil Depth (inches)
—dP
—i?
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i) Soil Drainage: Internal
U
External
S
U
(SS
t7'
S
V
i) Restrictive Horizons
Available Space
S
S
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
A
U
U
1) Site Classification
.bV
�S
i
U—UNSUITABLE S—SUITABLE -EProvisionally Suitable
Recommendations /Comments:
Described by Title
SITE DIAGRAM /
X
DCHD (8.82)
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Date �e