575 Howardtown Rd (2) / (� .;► DAVIE. COUNTY HEALTH DEPA MENT
� .? � s - IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE€ Issued in•Compliance with G..S. of North Carolina Chapter X130 ilArticle'13c
Sewage'TreatmenY and Disposal Rules (10 NCAC 10A .1934.-.1968), Permit Number
Name� �7.` Date � i^z�gzS . 4297
Location
lop
Subdivision Name I Lot No. li• Sec. or Block No.
Lot Size �; House:— ! Mobile Home:'� I Business Speculation
No:.Bedrooms No. Baths .. r I No. in Family�� it
Garbage Disposal YES, NO
NO
�" Specifications for System:
Auto Dish Washer YES NO -
Auto Wash Machine YES NO ❑ y !`
ifCf'�X.S�t � •.
Type Water Supply`—.f i�`fl�
*This permit Void if sewage system described beloW,is not installed wit�hin'.36 months from date of issue.
. : ; ¢ . . it � '' •. ,
Improvements permit by
*Contact a representative of the Davie ;County Health Dep rtment forlifinal 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
.' ' s ^�r -�:: c�': �•f i�' FJ 1, -
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 waybej.-taken as a guarantee that the system will function
-satisfactorily.for,any given period of time: i
RECEIVED Awl: i 13J�6
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
e 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 q!J g,--
1. Permit Requested By Business Phone
2. Address # v
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 Sec. Lot No.
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 o7 7 )(ISO
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 t", showers y washing machine V
dishwashery sinks
8. a) Type water supply: Public Private —Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions s2 5 aauj ��•. .
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?
What type?
i
This is to certify that the information is correct to the best of my knowledge.
�/- //_ ? z I- 1� wk��
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
(J
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
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
d7) PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) /r P P PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils P - PS PS
"U U U U
4) Soil Depth (inches) S S S
PS PS
U Q--IJT U U
5) Soil Drainage: Internal S� S S
UPS PS
External S S
S �lTPS PS
U U
6) Restrictive Horizons
7) Available Space 4S S S
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 PS—Provisionally Suitable
Recommendations/Comments:
Described by v Title Date
SITE DIAGRAM
DCHD(6.82)