308 Klickitat Trail 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 C10 NCAC 10A .1934-.1968) Permit Number
Name f// %i'<,�,; t, �i - < -:i; Date �, mac.!/�='� i"Sf1 9
Locatio r c
161
Subdivision Name Lot No. Sec. or Block No.
Lot Size f�`% � House Mobile Home Business _— Speculation
No. Bedrooms — No. Baths �� No. in Family —
Garbage Disposal YESC] NO .0 Specifications for System
Auto Dish Washer YES ❑: NO p
Auto Wash Machine YES El NO
Type Water Supply c'
*This permit Void if sewage system described below is not installed within 36 months from date of issue. ,
S
Improvements permit by
*Contact a representative of the Davie County Health Dep rtment for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. lephone Number: 704-634-5985.
01
Final Installation Diagram: 1� �'l System Installed by
r
U
Certificate of Completion ' 'i !� Date'The signing 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 Z`I
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.
A Home Phone ! 9144.4 ra ! q
1. Permit Requested By Business Phone AnLa e-
2. Ad6ess,!/O— di'
3. Property Owner if Different than Above ' ��oe-/ld`&
Address
4. Permit To: a) Install Iter Repair
b) Privy. Conventional 'Other Type
Ground Absorption
c) Sub-Division Lot No.
5. System used to serve what type facility: HouseSeMobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions '9
Bed Rooms411 ,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)uCd/Z- AlMaa,1 -
7. Number and typeof wat�r-using fixtures:
commodes 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—
b)
imensions b) Land area designated tobuildingsite
c) Sewage Disposal Contractor/�40,2"12'" e e F'h11',27 nG 4
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:
Q� /72 `
GZd 7yy Cr7 V �
X12
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date
Address r Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
NP ) ® PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) P18l PS PS
U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
<:::!p U U
4) Soil Depth (inches) S S S S
PS PS
U U
5) Soil Drainage: Internal S S S S
PS �PS� PS PS
L� U U
External S S S S
p PS PS PS
-� 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
U—UNSUITABLE -,S—SUITABLE Prov_ isional yi Suitable �
Recommendations/Comments: �✓/'�/S� (/��'/y��
Described by C- ' Title Date j
SITE DIAGRAM
DCHD(6-82)