548 Fairfield Rd (2)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 fiumber
Name\\ � N2
Date
Location \ _:` - I ' 1 ��
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home — ✓ Business —_ Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES :❑ NO [( Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES [T NO ❑ ti
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
Certificate of Completion Date
/ -��li
'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.
T APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 R r
Mocksville, N.C. 27028 �CC/�/rQ C% 3 1
X88
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By �r t "
2. Address • E)D)C �310
3. Property Owner if Different than Above Do (--xa`A -F) • �)e--ar)
Address �k- , ri (3,;D -'r- 3 1 O
4. Permit To: a) Installer Alter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone—
Business Phone
Vc Arlo
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home.%& Business
Industry Other
b) Number of people c2
6. a} If house or mobile home, state size of home and number of rooms.
House Dimensions Q-125
Bed Rooms._ Bath Rooms I 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:
Ca3y -3y- 50
commodes I urinals garbage disposal
lavatory showers 1 washing machine
dishwasher sinks a
8. a) Type water supply: Public— Private Community
b) Has the water supply system been approved? Yes Noy
9. a) Property Dimensions I otraft-
b) Land area designated to building site
c) Sewage Disposal Contractor nr. M, Ii C f
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Kh
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Com, K� tax__,_
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DCHD (6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��\� �, �C Date } j G -
Address Lot Size
AREA 1 1 —A AREA .1 ARFo d
1) Topography/ Landscape Position
PS
U
U
S
PS
U
S
PS
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
PS
_
PS
S
PS
U
S
PS
U
3) Soil Structure (12-36 in.)S-.
Clayey Soils
�p
U
PS
S
PS
U
S
PS
U
1) Soil Depth (inches)
( P�/
-�
S
S
S
PS
U
S
PS
U
i) Soil Drainage: Internal
PP *J
T
U
S
PS
U
S
PS
U
External
S
PS
S
PS
U
S
PS
U
i) Restrictive Horizons
—
Available Space
PS
PS
U
S
PS
U
S
PS
U
I) Other (Specify)
S
PS
S
S
PS
U
S
PS
U
1) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
SE PS—Provisional
\ -\,::,
Described by �- Title-'��'�r Date
SITE DIAGRAM
DCHD (6-82)