692 Greenhill Rd IV
�. DAVIE COUNTY -HEALTH. .DEPARTMENT."
IMPROVEMENTS 'PERMIT AND� CERTIFICATE -OF COMPLETION ,
"NTE:-Issued in;Compliance with G.S. of North Carolina 'Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC.10A .1934-.1968) . Permit Number .
Name Date s� 3 , �-1, 5-
Location /� = •�i/' /7;L, 0/_
Subdivision NameLot No. Seo, or Block No.
Lot Size House Mobile Home BusinessSpeculation .
No. Bedrooms No. Baths i' No. iri Famil ,
Garbage Disposal YES 0 NO- J;�'rSpecifications for.System`
Auto Dish Washer YES NO '•p
Auto Wash Machine YES NO
Type Water Supply -.� � _— .. •--�.�''l�l���i{J.:�� � +�-a���"
YP — =-�
*This permit Void if sewage system described ,below is not.installed within 36 months from date of issue. '
• � •? Improvements permit-by. _
*Contact a representative of the Davie County Health Department for final inspection, of this .system between. 8:310- .
9:30 A.M. or 1:00-1:30 P.M. on. day of completion..Telephone Number: 704-634-5985.;
Final Installation Diagram 1 b `'�' �Sy3tpam Installed by
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. 4.
•hs ..
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department MAR
Environmental Health Section O
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Re ted By / r G-QO usiness Phone
2. Address a1 d C
3. Property Owner if Differ�nt than Above
Address T 0 C-
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 Homea7�siness
/ Industry Other—
6. b) Number of people
6. a) If house or mobile home, state size of h me 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 garbage disposal `
lavatory 2 showers i washing machine 1
dishwasher sinksV°�� 0l N '
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No_Ic_
9. a) Property Dimensions I he- 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?
What type?
!� This is to certify that the informa ' n is rect to the be f my kno ledge.
t Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Aet
DCHD(6-82)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
/ SOIL/SITE EVALUATION �/ p�
Name � ' «-�'B� W Date XZ. �O
Address Lot Size l yw
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S SPS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) �P� PS PS
U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS
d' U U
4) Soil Depth (inches) S S S S
PS PS PS PS
® U U
5) Soil Drainage: Internal S S S S
PS PS PS
&5 <�F U U
External S S S S
PS PS PS PS
U U
6) Restrictive Horizons L /P �� r
7) Available Space ev ns S S
PS PS PS PS
U U U U
8) Other (Specify) l��'�LI ��l a eD S S
/ PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Titley'" Date _
SITE DIAGRAM
'i
UCHD(6 82)