578 Junction Rd - Longview Lots 11 & 12• DAVIE COUNTY HEALTH DEPARTMENTC.tt6a? �J
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 Date 3.)
e
Location — J-) f -a d e �1 r 21.).
_
Subdivision Name Lot No. Sec. or Block No.
Lot Size _LAX :?,.c -V House Mobile Home Business __ Speculation
No. Bedrooms No. Baths No. in Family_
Garbage Disposal YES ,F� NO [;I Specifications for System: 1 u oU ri rJ-
Auto Dish Washer YES g NO p _
Auto Wash Machine , YES Q NO � p _ "�� `�. la "" 'X '�,� v "5,).,�,x,2 '°,r��t:.G
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by_��� r�..
C1 -
*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
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 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name O1% S p: I I vn, Date
Address Lot Size Fla X 36&
Y-.^
FAr.TnRS ARFA 1 ARFA 9 ARFA R ARFA d
1) Topography/ Landscape Position
S
S
S
S
cl!�!>
425__>
(2!D
PS
4."
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
`�� S
G n S
S
S
Loamy, Clayey, (note 2:1 Clay)
Z, PS
i�
t PS
eg:�
2; PS
M>
PS
U
S) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
<C9::>
C -111D
U
i) Soil Depth (inches)
S
S
S
S
PS
3° U
PS
30" U
PS
3D " U
PS
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
External
S
S
S
1��
S
PS
U
U
U
U
i) Restrictive Horizons
5.e " _
Available Space
S
S.
S
S
PS
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
I��
l! -f
(—U—UNSOITABLE_�) S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: w n--C� war✓
Described by� Title Date
SITE DIAGRAM
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APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT v -
Davie County Health Department -
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address d
3. Property Owner if Different than Above
Address
- _-Z
Home Phone "-Y-
Business Phone
4. Permit To: a) Install ` Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-DivisionSec. Lot No. J-2-
5. System used to serve what type facility: House Mobile Home ✓ Business
IndustryOther
b) Number of people -;!-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Z Bath Rooms -V 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 urinal
lavatory -2 showers
garbage disposal
washing machine f
dishwasher sinks
8. a) Type water supply: Public Private Community r
b) Has the water supply system been approved? Yes ` No
9. a) Property Dimensions A 'O'ar
b) Land area designated to building site
c) Sewage Disposal Contractor 22r /1.•�orc
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? )ZO
What type?
This is to certify that the information is c ct to the best of my knowledge.
Date Owrx7r Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: ,
DCHD (6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665 y
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
S
l w ca
Date
2-- 2 7
®
<PN>
Address
PS
n 2-
Lot Size
gS ��C3bf
U
Vv�
'.) Soil Texture (12-36 in.) Sandy,
PAr'Tt'1Qc AREA i AREA 9 ARFA R ARFA A
Topography/ Landscape Position
S
S
S
S
®
<PN>
PS
PS
U
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
-0:>
PS
U
PS
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
L) Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
External
S
S
,-
PS
P$
U
U
U
U
1) Restrictive Horizons
Available Space
S
S
S
PS
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
1lf
— S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: e -e-1 cls �a-�-i 4-
'�� .tr�.eL o�.-P 1,.r2n"e,l.� �rt�.c.•e.� t .s1 - ri�T " • Z Gxs,�. rrv�e.+
Described by�"�'' Title Date
SITE DIAGRAM
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DCHD (6-82)
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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 62'1/--s'�
1. Permit Requested 4> 1c77 Z Business Phone
2. Addresso
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,Z'"g2,yl Q Sec. Lot No.
5. System used to serve what type facility: House Mobile Home- _t�usiness
IndustryOther
b) Number of people w-
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 I—
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensionsem .ass
b) Land area designated to building site
c) Sewage Disposal Contractor ,? j P-iz e.c/r�9�zrt
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 1Wo
What type?
This is to certify that the information is ct to the best of my knowledge.
Date Own r Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
pitv
))d..E.
DCHD (6-82)