917 Howardtown Rd (2) 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'Jreatmen.t and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �_ �, -> '.
=�- 5143
Location �-• � \-�•: J71
ZI
Subdivision Name J ! Lot No' ec: or Block No.
Lot Size �, House {i Mobile Home _✓ Bu'siness Speculation
No. Bedrooms No. Baths N No. in Family
Garbage Disposal YES ❑ NO [w
,, Specifications iifor System:, ,
Auto Dish.Washer YES p",NOV. J0 b
Auto Wash Machine `YlE$t �' NO ❑ "M
F,
Type Water Supply
�j
'This permit Void if sewage system described below is not installed .within 36 months from date of issue.
ji
�.'"`�..;.�..I....-.,.�,-•,rte-".� .�P--� .;� i
6 J ,
Improvements,permit by v -�''
-_
"Contact a representative of the Davie County Health Department for final inspection of this system' between 8:30-1 .
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephon Number: 704-60- 4-5985./
li
#� i� Illy
Final Installation Diagram: S System Installed by li
�r
Certificate of Completion Date
'The signing of this certificate shall indicate that the system described above has been,installed incompliance 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 ; i. '�
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
C Davie County Health Department
Environmental Health Section
1 P. O. Box 665C, :`' rn
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone a-70Y
1. Permit Requested By aero V N;Ven S -i /n,� KO /y r u Pns Business Phone9Q y �5�5(wee-T�„e)
2. Address t2)
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
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /L/ x t,O
Bed Rooms a Bath Rooms 1 Yz Den w/Closet
6) 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 2 urinals garbage disposal
lavatory Z showers / washing machine—F
dishwasher — sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes V No belon5 s to Dam e Coin 4-y
9. a) Property Dimensions .71n Of c.-n CSC r e—
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? Al D
What type?
This is to certify that the information is correct to the best of my knowledge.
q - lI - 8F /�4
Date Own r Signature
OWNER IS SOLELY RESPONSIBLE,FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
(o q �aS�
o n Co r rxt4Z-c r at
L e-P 4 p r-i PO t.J o-r c,( -lo wr) - gc(,.
— 14o f_ s e
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 11)
FACTORS ARE AREA AREA 3 AREA 4
1) Topography/Landscape Position SS S S
�S�' 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 U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils � <M PS PS
U U U
4) Soil Depth (inches) S S S S
• PS PS
U U U U
5) Soil Drainage: Internal S S S S
(jes-' PS PS
U U U U
External S S S
4�k Irps I PS PS
U U U U
6) Restrictive Horizons
7) Available Space S �, S S
CJS PS PS
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 —Provisionally Suitable
Recommendations/Comments:
Described by Title
car.` Date
SITE DIAGRAM
1
DCHD(5-82)