493 Duke Whitaker Rd (3) DAVIE COUNTY HEALTH DEPARTMENT Cr g
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-.1968) Permit Number
Name c ,� '�1 �`ti ,�'.� �,, a_ '� 1-5 Date j, (l F-7�_
Location �;7 cy.
U
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family h —
Garbage Disposal - YES ❑I NO' Specifications for System:
Auto Dish Washer YES NO,
Auto Wash Machine YES pf O p U 0
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
1
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 Diagra System Installed by
c�
a
1 a
-------------
N
r
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.
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}%.`.. ►• DAVIE COUNTY HEALTH DEPARTMENT
14
" 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-.1968) Permit Number
Name , �c� ���� t \ �i �-� Date
Location "
�� . ": .. till , 1 1\. r.,•4_ �, ---- -
Subdivision Name Lot No. Sec. or Block No.
Lot. Size House Mobile Home Business Speculation
No. Bedrooms No. Baths J No. in Family —
Garbage Disposal YES p NOS
"v _
pecifications for System:
Auto Dish Washer? YES p( NO 'O ��OT, ;•:�-- r ,�=: - �= .,)�
Auto Wash Machine YES Q, NO
Type Water Supply ---
*This permit Void if sewage system described below isnot installed within 36 months from date of issue.
1
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 Diagra System Installed bytir� �
Certificate of Com
N letion \� ��'�►"`=� 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/IMPROVEMENTS PERMIT -�
Davie County Health Department utl 0 9
Environmental Health Section O
P. 0. Box 665
Mocksville, N.C. 27028 R
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requ s ed By Business Phone 9qY-9o�.S�G
2. Address l
iUA
3. Property 0 ner if Different than Above
Address -6-3 e. d
4. Permit To: a) Install,&ZAlter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home4lZ6usiness
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions—
Bed
imensions 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
8. a) Type water supply: Public Privateer Community
b) Has the water supply system been approved? Yes No-
9. a) Property Dimensions yd'gcz
b) Land area designated to building site
c) Sewage Disposal ContractorUX
10. Do you anticipate any additions or ex a sions of the facility this sewage system is intended to serve?
What type?
This is to certify that the information i co ct to the best of my knowledge.
/'�-/ g/
Date "Owner S)gnature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
S IL/SITE EVALUATION
Name Date
R) - il - g7
Address Lot Size �-
FACTORS ARE 1 AREAn AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS
U
U U
2) Soil Texture (12-36 in.) Sandy, _rte S S
Loamy, Clayey, (note 2:1 Clay) PS's, ''-� � PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S
PS PS
U
U U U
5) Soil Drainage: Internal -�-� S S
(P� PS PS
U `C�f U U
External �, S S
pg �J PS PS
U U U
6) Restrictive Horizons
7) Available Space S S
pg PS PS PS
U U
8) Other (Specify) S S S S
PS P PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUI PS—Provisionally Suitable
Recommendations/Comments:
Date
Described by Title
SITE DIAGRAM
l
/ 00
DCHD(6-82)