P3414 Cherry Hill Rdtr 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 ��ST__�/,�1-- tf. fr' Date .�i r' aR0 314
1 ,. M.
Location ,� 1 ��,'-/ `' -,.; .- ,r
Subdivision Name Lot No. Sec. or Block No.
Lot �Size- -`" House � -- � Mobile Home — Business —_ Speculation
No. Bedrooms `- No. Baths ` 1 No. in Family _
Garbage Disposal YES O NO 0-- Specifications for. System;,.
Auto Dish Washer YES Q NO ❑ i, �-� < „ ,
Auto Wash Machine YES j NO ❑
Type Water Supply
''This permit Void if sewage system described below is not installed within 36 months from date of issue
� �r1
%=1%
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:
;t
11 F411
"t 3 --
_1� t.A �
System Installed by
.1. ��t�' ten•. r.. _ �U w,..---
IVsVIt: Ilan ;.4J- .4.4/c— �../,l,C% fi
. Yh a,,(� 3 - Iy - V�
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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address ^ Lot Size Ckl.Z
FAf TIIRR AREA 1 AREA 9 ARFA 3 AREA A
Topography/ Landscape Position
PS
S
�
S
PS
S
PS
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
PS
S
PS
Loamy, Clayey, (note 2:1 Clay)
U
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
®
S
PS
S
PS
U
U
U
U
') Soil Depth (inches)
S
SS
1S/
PS
S
PS
< ��
U
U
U
U
�) Soil Drainage: InternalS
S
PS
S
PS
U
U
U
External
S
PS
S
PS
S
PS
S
PS
U
U
U
U
I) Restrictive Horizons
Available Space
c
PS
PS
S
PS
S
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 S—SUITABLE PS—Provisionaliv Suitable
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
Title
Date
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.
Home Phone 284-2641
1. Permit Requested By R; l l f Brenda FPncjPr Business Phone 284-2581
2. Address Rt. 4, Box 176, Mocksville, N. C. 27028
3. Property Owner if Different than Above
Address
4. Permit To: a) InstaIIX— Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House_)�X_ Mobile Home Business
IndustryOther
b) Number of people 4
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms.— Bath Rooms 2 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:
1 commodes 2 urinals
lavatory 4 showers 2
dishwasher 1 sinks 2
8. a) Type water supply: Public Private .'i Community
b) Has the water supply system been approved? Yes No
9.a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor , (-I 1 /j 6i
10. Do you anticipate any additions or expansions of the
What type?
garbage disposal
washing machine 1
This is to certify that the information is correctto the best of my knowledge.
AiiMis - 24, 1983
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
601 South to Greasy Corner. Turn left on 801. Go approxim�at{ely 2 miles to Cherry Hill Rd.
Turn right. Go approximately 1 mile. Property in on the �t right before crossing
creek.
DCHD (6-82)
tr 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 ��ST__�/,�1-- tf. fr' Date .�i r' aR0 314
1 ,. M.
Location ,� 1 ��,'-/ `' -,.; .- ,r
Subdivision Name Lot No. Sec. or Block No.
Lot �Size- -`" House � -- � Mobile Home — Business —_ Speculation
No. Bedrooms `- No. Baths ` 1 No. in Family _
Garbage Disposal YES O NO 0-- Specifications for. System;,.
Auto Dish Washer YES Q NO ❑ i, �-� < „ ,
Auto Wash Machine YES j NO ❑
Type Water Supply
''This permit Void if sewage system described below is not installed within 36 months from date of issue
� �r1
%=1%
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:
;t
11 F411
"t 3 --
_1� t.A �
System Installed by
.1. ��t�' ten•. r.. _ �U w,..---
IVsVIt: Ilan ;.4J- .4.4/c— �../,l,C% fi
. Yh a,,(� 3 - Iy - V�
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.