138 Kinder Ln (2),.....:..-....r-',`hvFe•rcc^-n�-..-.•"._.;:,t 4. :.+•... : �,,.. >:�:. ,a :iw;�.,,v t?s';xJnjs _'S,.-, i. a`4a ;f..o .. ... ,l;fya(,�i' ., tt ,k. v
+' 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 � �. -ham ,,a ,:% Date � ,,�' ,�- .,
4 16
Location //�';1,. , .�.�1vT�,�.� J"
Subdivision Name Lot No. Sec. or Block No.
Lot Size f% ' " �✓ ^?�_ House Mobile Home �/J Business Speculation
No. Bedrooms , � 2 — No. Baths ' No. in Family —
' Garbage Disposal YES ❑ NO p-
Specifications for System:
Auto Dish Washer YES NO ❑ .
e1 f :-"�,/
rte`
Auto Wash Machine YES, NO -E]
J �G'� /� r
Type Water Supply ---
- _, •fit
`This permit Void if sewage system described below is not installe .d- wit 'n 36 months from date of issue.
r
*Contact a representative of the Davie County Health C
9:30 A.M. or 1:00-1:30 P.M. on day of completion. T
5•
Improvements permit by
r 1 Ment fo in inspection of this system between 8:30-
none N ber: 704-634-5985.
Sys em 1 stalled by
�d SO
s
Certificate of Completion �j� 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.
,
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department °p
Environmental Health.Section �� n
P. 0. Box 665
Mocksville, N.C. 27028 ;��
15�A
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. ;P
�/ Home Phone 9
1. Permit Requested By �9'�� ✓7'1 • �r• ,�a��w (,rte - Business Phone
2. Address P 0- Aq, �;C� �'/cr�a.,,,� i✓--a70/L js3' -MEdty—,v RJ.
3. Property Owner if Different than Above
Address
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 Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes `_'No
9. a) Property Dimensions /00 x 7-0.0 F /
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.
y- /s - g)G 04'f�^. / 6�j
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Tri-, Its �
DCHD (6-82)
•e .
Name—
Address
Xe�Lllcv
FA CTn R!4
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 1 ARFA 2
Date-�
Lot Size7At_�al-1e��
AREA 3 AREA 4
1) Topography/ Landscape Position
S
�
U
S
PS
U
S
PS
U
') Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
PS
U
S
PS
U
1) Soil Structure (12-36 in.)
Clayey SoilsPS
S
PS
U
S
PS
U
i) Soil Depth (inches)
p
S
PS
U
S
PS
U
) Soil Drainage: Internal
(lip
PS
S
PS
U
S
PS
U
External
P;)
/(P
�j
S
U
U
S
PS
U
U
Restrictive Horizons
Available Space
g
j PSS
�i
S
PS
U
S
PS
U
1) Other (Specify)
S
PS
S
PS
S
PS
U
S
PS
U
I) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
Described by / Title Date
SITE DIAGRAM
DCHD (8.82)