P5910 Hwy 801SDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE- Issued in Compliance With Article 11 of G.S. Chapter 130a
anitary Sewage Systems Permit Number
Name Ji' ;fig .t-1 , ,�;, �� Date ���� ilk
N° 50.0
Location /X2t
Subdivision Name
Lot No,
Sec. or Block No
Lot Size / is ' )( i 9y House Mobile Home _k/ Business Speculation
No. Bedrooms 4- No. Baths ___ No. in Family -
Garbage Disposal YES ❑ NO p' Specifications for System:
Auto Dish Washer YES D- NO NO ❑
Auto Wash Machine YES D -'NO ❑
Type Water Supply
*This permit Void if'sewage system described below is not installed within 5 years from date of issue.
This permit is subject to revocation if site plans or the intended use change.
Q 'r7
4X,
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 _%Ja ' kN
r
y.
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665 RECEIVED MAR ) 9
n ft�iv Mocksville, NC 27028
1. Application/Permit Requested By
Mailing Address 20-
Home Phone Business Phone
2. Name on Permit if Different than Above
3. Property Owner if Different than Aboveic�n�.
4. Application/Permit For: 0 General Evaluation JJ3/S/Tank Installation
5. System to Serve: House � obile Home 0 Business
0 Industry u Other 0 Unknown
6. If house, mobile home: Subdivision
No. of People
No. of Bedrooms
No. of Bathrooms ly2
Washing Machine
Dwelling Dimensions
Sec. Lotu
Basement/Plumbing
Basement/No Plumbing
J Dishwasher 0 Garbage Disposal
7. If business, industry, other: Specify type
No. of People Served
No. of Commodes
No. of Lavatories
No. of Showers
No. of Sinks
No. of Urinals
No. of Water Coolers
8. Type of water supply: VPublic 0 Private 0 Community
9. Property Dimensions/ IS L-ef-- 5
10. Sewage Disposal Contractor
11. Do you anticipate additions/passions of the facility this system is
intended to serve? 0 Yes FNo
If yes, what type?
*NOTE: Improvements Permits shall be valid for a period of 5
years from date issued. Improvements Permits are subject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
This is to certify tnat the information provided is correct to tree
best of my knowledge, and I understand I am responsible for all
charges incurred from this application.
full AIL,
Date Signature
Directions to Property:
( ay- AN //a pa -v- '16a)
DCHD (10-89)
i
Address
FAr.Tr1RC
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA i ARFA 9
Lot */ /J./ •
AREA 3 AREA A
I) Topography/ Landscape Position
Q
PS
d)
PS
SS
PS
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
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TTT���
U
U
3) a (12-36 in.)
Clayey Soils
Clayey
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&
S�
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U
U
U
U
1) Soil Depth (inches)
A
s
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U
i) Soil Drainage: Internal
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d
U
U
U
External
S
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S
U
�) Restrictive Horizons
Available Space
SA)
/
U
U
U
U
o) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
i) Site Classification
U—UNSUITABLE S—SUITABLE PS=Provisionaliy Suitable
Recommendations/ Comm
Described by Title �l' Date 3
SITE DIAGRAM
x �
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DCHD (6.82)
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