475 Fred Bahnson Dr (5) DAVIE COUNTY HEALTH DEPARTMENT
1 IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1/968) Permit Number
rmber
iName ����'+' ��/;r�.i,�,� /t- ';���/_ , '',!Date V /�/P/ C "D3
2;r3' �
Location . /'� — ��✓ �' ��� /
Subdivision Name Lot No. Sec. or Block No.
Lot Size - C House Mobile Home _ Business Speculation
No. Bedrooms No. Baths s. No. in Family _
Garbage Disposal YES ❑ NO [x' Specifications for,System:
Auto Dish Washer YES NO ❑ iyl�z f, „ ,r'
Auto Wash Machine YES NO ❑ v C, �_
Type Water Supply I/'LeZ'�%
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
.a
1
Improvement ermit by
*Contact a representative of the Davie County Health Departnt for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. T�e(Shmeone Number: 704-634-5985
Final Installation Diagram: y� ystem Installed by
1 /
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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date ��
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS
4–�
U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils ® PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS
U U U
5) Soil Drainage: Internal. S S S
p PS PS
U U U
External S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space c� S S
Pg CtD PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U� U ^ U U
9) Site Classification 11= ,, . -5
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title ��� Date
SITE DIAGRAM
r
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone sots
1. Permit Requested By %��a lac' Ca. Business Phone
2. Address ecxe,e, }{0"�per\. R1. \',�>- S. V_') C' k
3. Property Owner if Different than Above Gt'aa ancA
Address Zoo- 0rA'
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-DivisionSec. Lot No.
5. System used to serve what type facility: House Mobile Home—Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state sizg of home and number of rooms.
House Dimensions 3S'' !ao� )��►
Bed Rooms 3 Bath RoomsDen 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 3 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property DimensionsC'oa p-
b) Land area designated to building site aG�s
c) Sewage Disposal Contractor Tv �p'3 �oP4�e. `arm e;C3
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 Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6.82)