173 Houston Rd 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 �n �' �7' % 1r�.f✓� Date /'-" N2 577,33
Location __ 111_2l Zs-
Subdivision Name
' Lot No. Sec. or Block No. 1.
Lot Size �� House Mobile Home _ .ef::f Business' Speculation
No. Bedrooms _ No. Baths No. in Family _
Garbage Disposal YES p NO p-'' v Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES �j NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within.36-months from date of issue.
Improvements permit by ZZ
`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: �� t stem nT`sfaffed by
j
X
FNOay
Certificate of CDate"The signing of this certificate shall indicate that the syibed above has been installed in compliance with
the standards set forth in the above regulation, but shallln 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 RECEIVED MOV 15 mg
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit R ted By At3mnIrlAd Business Phone
2. Address
.-3. Property.Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional �ther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility:House Mobile Home Business
_ IndustryOther
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions / X 74
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 PrivateCommunity
b) Has the water supply system been approved? Yes �No
9. a) Property Dimensions—
b)
imensions b) Land area designated to building site y L
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
dols• ;Lf ox• zy.
I/D o fGl�S
-?4dfs,eT,� FY 7#1�� ��14_5,oe &See)
*NOTE: Improvements Permits shall be valid for a period of S .
ears from date issued. !
Y Improvements Permitsaresubject
to revocation, if site plans or the intended use change.
Effective October 1, 1989.
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size 1 �
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position
` s, PS PS `�S
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) nj' �-
U U U U
3) Soil Structure (12-36 in.) S SS
Clayey Soils (� P c;8'
Tj U U
4) Soil Depth (inches) S S
5) Soil Drainage: Internal � Sgo
-b
U U
External ts�
_.
- PS
6) Restrictive Horizons
7) Available Space osJ
PS FS PS 0S
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U UU U U
9) Site Classification - . ,\ 4 ,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �( Title �-�-� Date b
SITE DIAGRAM
Y
N/
DCHD(6-82)