612 Gladstone 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 Treatment and Disposal ules (10 NCAC 10 .1934-.1968) Permit Number
Name %., T i✓ ,l '// 6rare,> l/ N2 5449
Location �� :' ��– ,!' .� x7
Subdivision Name / Lot No. Sec. or Block No.'
Lot Size House `�Ktl �"�lfcr✓J�%�� !�R��
'" obile Home _ Business Sp eculation
No. Bedrooms ' No. Baths No. in Family_Z�-
Garbage Disposal YES O NO Specifications for System:
Auto Dish Washer YES � NO p X C1 y
Auto Wash Machine YES A] NO ld 0,/+-
Type Water Supply
—
*This permit Void if sewage system described below is not installed within 36 m n ssue.
i3
------
Improvements permit by �
*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: System Installed by L)sr�, "
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 way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROV,
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
1. Permit Re uested By ,, .S� Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install lG Alter Repair
b) Privy Conventional_s��Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOtherl.l
b) Number of people
6. ar If house or mobile home, state size of home and number of rooms.
House Dimensioon��s��JJ
Bed Roomsl/5/X 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 a showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensions s '
b) Land area designated to building to
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 Owa6r Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
�E DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
`SOIL/SI�TE,EVALUATION /
Names �` +J Date`
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
S
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) 0
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils (§ p �
U S
�U'j
4) Soil Depth (inches) /��/, _`� S-_
U U U
5) Soil Drainage: Internal S
0> ($1 %-111- ($3
External S
c�sS
- U
6) Restrictive Horizons
7) Available Space 9SS 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 ZS--Provisionally Suitable
Recommendations/Comments:
Described by� Title Date
SITE DIAGRAM f
DCHD(6-82)