105 Wolf Ln V
Y DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND 'CERTIFICATE-OF COMPLETION
y �' `NOTE: Issued,in-Compliance with G.S. of North CarolinaChapter130 Article 13c
Sewage`Treatmen and Disposal Rules (10 NCACi,10A .1934-.1968) Permit Number `
to r �Name
Location �f'JX 3� .�in✓i ✓_3r� % •� �.. .r., elf i r A%'� _
Subdivision Name Lot No. _ Sec. or Block No.
Lot Size House -,"Mobile Home Business Speculation
No. Bedrooms _ No. Baths No. in Family -2 _
Garbage Disposal YES p . NO Specifications for System:
Auto Dish Washer YES NQ
Auto Wash Machine YES NO
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date.of issue.
r'
t 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
"The signing of this certificate shall indicate that the system described above has beeninstalled 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. O. Box 665 RECOVED JAN 2 0
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone ?F?- f*71
1. Permit Re uested By ��aRIA Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Installv"*"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_Xe!:fBusiness
IndustryOther
b) Number of people oZ
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions a
Bed Rooms a 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 I 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 Z 1h
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? h)0
What type?
This is to certify that the information is correct to the best of my knowledge.
in
Date Owner 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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NEW LINE 312. 9 I' 101 .
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♦ N 8 8.2 9' 3 4"W PLACED -
SAMUEL T. CABLE
FOUND -� �
GERALD B. WILKIE
D. B. 1 19 PG. 32
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GRAPHIC
MAP D E
1 JOHN RICHARD HOWARD caRih► that '"��jt FOR
this map was drawn tram an actual �% _ y' Sc _-
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name G1/��� Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) / / PS PS
U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils _VS, PS PS
U U
4) Soil Depth (inches) S S S S
- ) PS PS
`-lT U U
5) Soil Drainage: Internal S S S
((P,9 PS PS
U U
External S S S
PS PS
U —49 U U
6) Restrictive Horizons
7) Available Space S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification -S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: s
Described by �// Title Date
SITE DIAGRAM
(1
DCHD(6-82)