752 Duke Whitaker Rd DAVIE COUNTY HEALTH DEPARTMENT
�r IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 1%b0
* ssued 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 L z at �1 E �� \ L�. Date � ' ��c4 �`b N� ��V g
Location �T y� �� o�- 5y ►�� _ � .
Subdivision Na a Lot No. Se6. or Block No.
Lot Size R House — MAile,Home _ Businessf, Speculation
No. Bedrooms f No. Baths No. in Family QL _
Garbage Disposal YES -C] NO Specifications for'lSystem:
Auto Dish Washer- YES p Nod
Auto Wash Machine YES'[ NO
Type Water Supply _—
*This permit Void if sewage systerri.described below is not installed`within 36 months from date of issue.
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Improvements permit by(\ S
*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 A m N A \-\a Q
Certificate of Completion Date 1
*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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*' APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT u� 13
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Davie County Health Department .SID
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home PhoneT
1. Permit Requested By
Bu si ss Phone
2. Address e.
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conven.tional�zOther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: Housed Mobile Home Business
IndustryOther
b) Number of people-
6.
eople 6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions eerx Sd
Bed Rooms C9' Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
WAt type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes l 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 Dimensions
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 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: RV a'4-c��
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
Name �2�y t= e �\c Date
Address c\'MLot Size / Ck 1
FACTORS A EA 1 ARA 2 AREA 3 AREA 4
1) Topography/Landscape Position _ S S S
PSj PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, 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
4) Soil Depth (inches) S S
S PS PS
U U
5) Soil Drainage: Internal /�� �, S S
Lam' ( P9► PS PS
U �tf U U
External S S
CP� PS PS
6) Restrictive Horizons
r
7) Available Space ,� S S
PS lr J PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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UCHD(6-82)