P5024 Howardtown Rd DAVIE COUNTY HEALTH DEPARTMENT �0,3 a
'IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
,NOTE:. Issued in Compliance.with G.SJ of North Carolina Chapter 130 Article. 13c
Sewage Treatment.and
Disposal aRules (10 NCAC 10A .1934-.1968) Permit Number .
Name _ , DatefS' 024
Location
k, :
Subdivision Name ' Lot No. Sec. or Block No.
Lot Size 11 • '- House Mobile Home _ Business` Speculation
No. 'Bedrooms c? _No. Bathsi'"` No. in Family
I' —.
Garbage Disposal YES 0. NO•❑ Specifications for System:
' .Auto Dish Washer YES t 0 'NO /n r�' •. �c3�* . '� ': �`,
Auto Wash Machine YES ' '-NQ, p x t1
X
Type Water Supply . A) ."
this permit Void if sewage system described below is not installed within,36 months from date of issue.
`y ••�sl_.�v>� ��. ,h4 V A'.?�".mss ��i t 41 i
r I:
� it •. - ..
Improvements permit by
`Contact a representative of the Davie!County Health Department ford 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.
r N
Final Installation.Diagram: � � •System Installed by NO
u
i
.py
1
Certificate of Completion ` Date �r 3
"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. ii
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department D�
Environmental Health Section '
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 75�-_3�2
1. Permit Req ezted By Business Phone �� Q
2. Address NAMf _'11w_ Alc,
3. Property Owner if Different than Above C NA R2 5 &L, _
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.Z
5. System used to serve what type facility: House Mobile Home V Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 nn garbage disposal x
lavatory showers cam, washing machine
dishwasher 2 sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 1.-7 Sk k
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?
This is to certify that the information i c rect to the best of mynowt ge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�!-
Ct
- r3
DCHD(6-82) 1 \
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION �(
Name \e Date
Address � �` Lot Size
FACTORS AREa AREA AREA 3 AREA 4
1) Topography/Landscape Position S S
P PS PS PS
may/ U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS (t) PS PS
U U U U
4) Soil Depth (inches) S S
pg PS PS PS
U U U
5) Soil Drainage: Internal S S
p PS PS
U U
External S S
PS PS PS PS
U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE p P ro�sio_nalQiy Suitable
Recommendations/Comments: �`�+� 4 `
Described by �- �a Title Date
SITE DIAGRAM
1
DCHD(6-82)