P3283 Cherry Hill Rd�- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
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
Name A3c2T 6le'ed Date NJ;'} `, 2 ^ 3
Location 60/ JOCJTir L�`rT 01.1 �' GKrowN Kv. /�iylr4- o/V Glrlelel 1/1'([. /ZZ.
Subdivision Name Lot No. Sec. or Block No.
Lot Size ��� �` House _"_ Mobile Home "Business Speculation
No. Bedrooms 3 No. Baths Z No. in Family 3
Garbage Disposal YES ❑ NO E'
Auto Dish Washer YESNO [:jAuto Wash Machine YES Ll NO ❑
Type Water Supply
Specifications for System: /DOO /Z, -1-"--L
3oc� x 3 x /z s rva�
*This permit Void if sewage system describe b low is not installed within 36 months from date of issue.
r- izoN'i
*Contact a representative of the/Davi C
9:30 A.M. or 1:00-1:30 P.M. Q day of
Final Installation Diagram:
Improvements permit by
ity Health Department for final inspection of this system between 8:30-
mpletion. Telephone Number: 704-634-5985.
System Installed by Wo
Certificate of Completion Date �<
*The signing of this certificate shall indicate that the system describ d above has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be ken as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �g�Z� 6�u Date , S- g3
Address �? �"X Zs 7 Lot Size
nt0r-&.5v'(wc_ lie. 27 o z -P'
FAr.TnRS ARFA 1 AREA 2 AREA 3 AREA 4
9
1) Topography/ Landscape Position
6P
S
S
PS
PS
PS
U
U
U
U
�) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
OP
S
S
PS
47
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
�S
S
S
---d5
S
PS
(
U
U
U
U
)Soil Depth (inches)�
�
�
S
PS
U
U
U
U
) Soil Drainage: Internal
��
S
S
PS
PS
PS
U
U
U
U
External
115'
S
S
PS
PS
PS
PS
U
U
U
U
) Restrictive Horizons
Available Space
S
S
PS
- PS
PS
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by —
SITE DIAGRAM
S—SUITABLE (S --R( isionaliy Suitable
Title S,4/ 17-A P
DCHD (6-82)
Date f S-- F
r.
DCHD (6-82)
Date f S-- F
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requ
2. Address —
3. Property
Address
Home Phone(_47M ` 9Q8"•212(/
Business Phone (70'y) ..(,337.. 23Z
4. Permit To: a) Install Alter Repair �
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
—
Industry—
IndustryOther
b) Number of people IfZ e (3)
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions (m! tl&J IV �/
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 urinals llPdAIA uK
lavatory �i showers 'f
dishwasher sinks
8. a) Type water supply: Public ° Private Community
b) Has the water supply system beena��//pproved? Yes No
9. a) Property Dimensions '5 k arses
b) Land area designated to building site
c) Sewage Disposal Contractor nD a.,
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
garbage disposal a --
washing machine vis
What type?
This is to certify that the information is correct to the best of my knowledge.
Date 0 er Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)