333 Rollingwood Drive Lot 6 Section 3' DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE •,OF COMPLETION
*NOTE: Issued in Compliance with G,8. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date 3 _'z'd —F5
Location .//, .G -Zt4ej - /,�j7- 7t / C�
Subdivision Name S--44.wt ,n (1 Lot No. Sec. or Block No.
i
Lot Size 4 -'. 90' House ✓ Mobile Home _ Business - Speculation
No. Bedrooms 3 No. Baths Z No. in Family .2 -
Garbage
Garbage Disposal YES [] NO Q. Specifications for System:
Auto Dish Washer YES E)- NC ❑ )< 3'X
Auto Wash Machine YES p• NOi ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
3
Improvements permit by
*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:
System Installed by
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 regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
r- DAVIE COUNTY HEALTH. DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NO"TE: 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
{
Name Cl. 1 Date —i!- FIP 3834
Location /., - 7 _,.i f,yi: /, i, ,.a/.,. / / ,:, _ /�,T /• 1 i ^ l
Subdivision Name
nZ
I
Lot No. Sec. or Block No.
i
Lot Size 1S4 d 3
90'
House
✓
Mobile Home _ Business Speculation
No. Bedrooms 3
No.
Baths
z
No. in Family -2
Garbage Disposal
YES
❑ NO
p•
Specifications for System:
Auto Dish Washer
YES
p- NO
❑
3 ' r
Auto Wash Machine
YES
p NO.
❑
- ' `� ' z o, F i
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
F
Improvements permit by
*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:
System Installed by
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 regulation, but shall in NO way be taken as a guarantee that the system will function
satisfactorily forany given period of time:
M
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
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Date
S
Address
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Lot Size
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Fer•.Tnac ARFA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
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!) Soil Texture (12-36 in.) Sandy,
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S
S
S
Loamy, Clayey, (note 2:1 Clay)
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i) Soil Structure (12-36 in.)
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Soil Depth (inches)
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CP
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i) -Soil Drainage: Internal
S
SS
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U
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External
PS
PS
PS
PS
U
U
U
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i) Restrictive Horizons
GL
r) Available Space
P
PS
PS
S
U
U
U
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3) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
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3) Site Classification
f
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U—UNSUITABLE S—SUITABLE CPS—Provisionally Suitabl8,
Recommendations/ Comments: �oz✓� ,a���^
7_0' 4e I! a_ e`er
Described byQ ✓ham--�) r – Title �^ �- e^ Q Date
SITE DIAGRAM— to PE
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 4�
Davie County Health Department
Environmental Health Section'
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
A I Home Phone b 3 %
1. Permit Requested By nY r C Business Phone
2. Address )� 0 H L C e� c S f- C st. V o e- W< l 1V C-
3. Property Owner if Different than Above
Address
4. Permit To: a) Install() ... Alter— Repair— _
b) Privy— Conventional— Other Type—
Ground Absorption
c)Sub-DivisionSQtdhwoOcChcSec.L Lot No. Lo e4 H
5. System used to serve what type facility: House Mobile Home— Business—
Industry— Other—
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Go 1 X 2-8 1
Bed Rooms 3 Bath Rooms Z 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 3 urinals garbage disposal
lavatory showers washing machine f
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No -
9. a) Property Dimensions 15-6f' X 3 8 0
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.
Aar. ! ,S_, 991 6-r-��
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
4!:�o /5 —
Z44.?L Xyt 0'
DCHD (6-82)
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