582 Burton Rd-�-*8 p..�b. Maca.+ d.s l.. sY.-R...H,.a.:6Y6.. -.,..�. ._..;5a�,•; a / ;�; '1 u:5.. J 7t ar4 ... ,.. - . . - .. ...
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DAVIE COUNTY HEALTH DEPARTMENT Qnn^
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION _J
`NOTE: Issued in Compliance with G.S.of North Carolina Chapter 130 Article 13c
Sewage Treatment and pisposal Rules (10 NCAC 10A .1934-.1968) Permit Number H
Name / J > � ;�' !l _� sT' N2 56601.
Location , - / ¢'_ �T� i /� ,,' 1 ,•'' ,;�^.� r?„i
Subdivision Name Lot No. Sec. or Block No.
Lot Size /A ell House Mobile Home _ Business Speculation
No._Bedrooms No. Baths No. in Family _
Garbage Disposal YES U NO Q' Specifications for,System:
Auto Dish Washer YES ®' NO ❑ �/ , °} �'.,
Auto Wash Machine YES,,o NO ',❑ GG A✓ c
Type Water Supply
*This permit Void if sewage system described below is Mot. rtst�lled vMhfW- 36 .months'from date.,of issue.
Improvements permit by-,-'
*Contact a representative of the Davie Cou ty, Health Departmentt� or final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of cwm letion. Telephone Nb ber: 704-634-5985.
Final Installation Diagram: i' 0 c+ System Installed
Certificate of Completions Date ! 7
*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
- Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
NSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
Q�;9A
Requested By o Business Phone
, . ss 20 P-36V P
3. Property Owner if Different than Above 0k) Pe-e b NOS
Address PC) 3nY,
4. Permit To: a) InstallZ Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. trot No.
5. System used to serve what type facility: House 1/ Mobile Home Business
Industry Other
b) Number of people c2.
6. a7 If house or mobile home, state size of home 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:
commodesurinals garbage disposal
lavatory ; showers washing machine
dishwasher / sinks
8. a) Type water supply: Public V Private Co munity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions3—X:
b) Land area designated to building site -t�'►v�/�
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A10
What type?
This is to certify that the information is corr t t e-bes 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:
mol
aoo
P p
P-or -
5
DCHD(8.82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date c:
Address Lot Size 01<
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S
U U � 0
2) Soil Texture (12-36 in.) Sandy, S S\
Loamy, Clayey, (note 2:1 Clay) PS
U
3) Soil Structure (12-36 in.)
Clayey Soils PS PS `tT P
4) Soil Depth (inches)
U ( PS
5) Soil Drainage: Internal
- External S
U U
6) Restrictive Horizons
7) Available Space S
PSI PS PS S
U U U U
8) 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: Q
Described by !'� l/ Title Date
SITE DIAGRAM
DCHD(6-a2)