P3093 Calahan RdJ, DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name J f����)-�� ,,��, Date </-
Location ^L, i+I-t'71'
- �.�1 1�'1( 1•�1!b�-.. ,.)I !�.r./r.1:n\�4^ �� ��.;�...�'Y- ht'1�
Subdivision Nanie Lot No. Sec. or Block No.
Lo I Size 6 r' House ✓ Mobile Home — Business Speculation
No. Bedrooms 2-- No. Baths No. in Family Z—
Gairbage Disposal YES ❑ NO p -"Z �n Y Specifications for System: c\00
AutAuto Dish Washer YES ❑ NO
❑• �,f1•a' 2 , ?, +�
Auto Wash Mac! ine YES p' NO C❑ '' '� 0 O x Y I
Type Water Su ply ! r 11 _
'T is permit Vo d if sewage system described below is not installed within 36 months from date of issue.
i
YP
Improvements ermit.b ' '\_i
P =��—�---
I
'Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
:30 A.M. or 11:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Iinal Installation Diagram:
<<1
System Installed by
Completion Date
Certificate of
;!�� j�"r
"IIThe 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.
`c
o APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT q Q
Davie County Health Department
Environmental Health Section I
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Req
2. Address —
3. Property O
Address _
4. Permit To:
5. System
Home Phone . a- � 647
By l-iNA6.4 Ai.Lkn-- Business Phone
� & I _R„ x 51-5 WdcA-S di ))& . K. X 7 0 2.
if Different than Above
Install3?!fAlter Repair /
Privy Conventional Other Type 13
Ground Absorption
Sub-DivisionSec. Lot No.
to serve what type facility: House Mome Business
IndustryOther
b) Number of people Z?_
6. a) If house or mobile home, state size of home and number of rooms. Y1�
House Dimensions 161d Fr2. rIki %)o v S
Bed Dooms Z Bath Rooms Den w/Clo*et IVO. C
b) If Busin ss; Industry or Other, State: Number of persons served
What pe business, etc.
Estim I to amount of waste daily (24 hours)
7. Number a d type of water -using fixtures:
1^a a ivy, .
commodes urinals garbage disposal
lavatory showers washing machine 1
dishw sher sinks
8. a) Type we ter supply: Public Private Community
b) Has the water supply system been approved? Yes - No
9. a) Prope I Dimensions�' C r e s
.2
b) Land all a designated to building site `� �•
c) Sewage Disposal Contractor= -
1i . Do you an Jcipate any additions or expansions~ the"facili _this -sewage system is intended to serve?�Q—
What type
Directions to
r o M
eke
C6 M
I�
c�ha� C
h6�sQ
�.6vSe.
This is to certify that the information is correct to the best of my knowledge.
Date v Owner Signature 1
ER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Dperty: ,
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Address
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date ^ 2d - V - Z.
Lot Size Acne -S
M,cK5J,1Ic-
Inc 2102r
FACTORS
AREA 1
AREA 2
AREA 3
AREA 4
1) Topography/Land
cape Position
S
S
PS
PS
PS
PS
U
U
U
U
2) Soil Texture (12-3
in.) Sandy,
S
S
S
S
Loamy, Clayey, (n
to 2:1 Clay)
(Inp
®
PS
PS
U
U
U
U
3) Soil Structure (12-36
in.)
S
S
S
S
Clayey Soils
cf�
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
S
(fn>
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
S
�S
4::M>
PS
PS
U
U
U
U
Ext
rnal
e
®
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizo
s
Sof" `�,i;-
meq, •�
Available Space
S
S
PS
S
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site IClassificatio
U—UNSUITABLE
S—SUITABLEPS—Provisional)Su'
ble
tecommendations/
omments: kr S Ate, \VX 0'M V'! -v "t A41
R
•
)escribed
by
"
-
Title & • IA '-`
2
Date
'ITE DIAGRAM
CHD (6-I 2)