P4599 Godbey Rd .:
DAVIE,COUNTY HEALTH DEPARTMENT . r
`: f . •. IMPROVEMENTS PERMIT AND D CERTIFICATE OF. COMPLETION V
TF: ,Issued in Campliance with G.S. of North Carolina Chapter,130 Article ,13c
Sewage Treatment and Disposal; Rules (10 NCAC�1 OA .1934-.1968) ' Permit Number.
_.` Name Date
ry, r
Location
Al
Subdivision Name 'I Lot.No. Sec. or Block No.
Lot Size
House Mobile Home _ Business;- Speculation
No. Bedrooms No. Baths 11 '�_ No. in Family --f
--r— s ,.
Garbage Disposal YES Ej NO'
1j v Specificatioris for System:
Auto Dish Washer . YES-,[D, NO'],
Auto Wash Machine YES .❑ ,Nd
ot
Type Water Supply'.
'*This permit Void if sewage system described below is not installed within 36 months from date of issue.
R
71
Improvements permit by
*Contact a representative of the Davie,County Health Department-for final inspection of this system between 8:307 .
Ell`
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 b
• ' ' ) O , - 6
D . 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.
RECL1.tj
co
e APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/� / Home Phone qW-
1. Permit Requested By rXe Business Phone
2. Address Q.1 6M &t l 6c14 .
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 -Z
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /'2'x ( b
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 / showers washing machine
dishwasher sinks r
8. a) Type water supply: Public Privateer Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions I V/4 aCV_AJ
b) Land area designated to building site (2 >
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 the best of my knowledge.
Zx'
11 - 0 - f6C -2
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-62)
S DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
\ SOIL/SITE EVALUATION
Name � Ay� � A'��Q �-�', Date
AddressLot Size �+
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1)'Topography/Landscape Position S S S S
PSS IP6��
1�S PS
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) &s
LLT.�' __u PS PS
-
3) Soil Structure (12-36 in.) S S S S
Clayey Soils -PS PS PS
o— Clj
4) Soil Depth (inches) S S. S S
PS PPS
6-,. �U (f UE)
5) Soil Drainage: Internal S S S S
IS:) \-U-
External S S S , S
PS
U
6) Restrictive Horizons �� i• , ,,.
7) Available Space - (-0 S S S
PS PS PS PS
U U U U
6) 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 tZ/ Title Date
SITE DIAGRAM
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o 64WX�l
DCHD(6.82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION c
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PS ( S PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) C* (:k�' PS
U U l7" U
3) Soil Structure (12-36 in.) SS
Clayey Soils PSS S PS PS
U U
4) Soil Depth (inches) S S S S
PS PS PS
U U, U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U U
External &– S
�p�' PS
U U U U
6) Restrictive Horizons
7) Available Space S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
oc U U U
9) Site Classification S S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title . Date
SITE DIAGRAM
Nowa
n
11
(31
DCHD(6.82)