2949 Cornatzer Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
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 Date
Location
-.-i. j'/� //Yi .. i_•�/?ii4...1 's is j,/` ZZ
Subdivision Name Lot No. Sec. or Block No.
Lot Size r711' House Mobile Home Business Speculation
No. Bedrooms �-F — No. Baths -,/— No. in Family _
Garbage Disposal YES E] NO p- Specifications for System:
Auto Dish Washer YES NO 'p
Auto Wash Machine YES [1] NO E]
Type Water SuPPIY _ • , ���-�C��=`'I�J:.1 �.
, f
*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 Diagram: System Installed by
�J
1 �
r
Certificate of Co 131'etong. Date
*The signing of this certificate shall indicate that.the s" ystem 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 t�
Environmental Health Section PN 2
P. 0. Box 665 �RIE0 ,
Mocksville, N.C. 27028 R�C+
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/ Home Phone 9q'F �9D.z
1. Permit Requested By /fR,&jy "IlreBusiness Phone
2. Address _ _- 6 IYok u 5 .4ch,-,a 9 a 4 11/4'. 2 loo A
3. Property Owner if Different than Above //4 v dL° ✓ 7.X%04Z ✓�1e�
Address tt-A 2 AC, `a h P e_ rV(V. 2_7 a s b
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 /G✓0
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /Z X ( 5�
Bed Rooms_—Bath Rooms 1 2— 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 2— urinals garbage disposal
lavatory 2 showers .0Z washing machine /
dishwasher O sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No-C/
9. a) Property Dimensions 3 herr S
b) Land area designated to building site
c) Sewage Disposal Contractor — &e4-
10.
e 10. Do you anticipate any additions or expansions of the facili y this sewage system is intended t erve? AOO'O
What type?
This is to certify that the information is co ect to the best of m knowled e.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
irections to property:
haute �/Zc�c�._. O yJ
CHD(6-82)
'r
DAVIE COUNTY HEALTH DEPARTMENT
- Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION p?�
Name u/��M�� Date
Address Lot Size ��
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) fvg1 PS PS PS
llu/ U U U
3) Soil Structure (12-36 in.) i t S S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S S
17" PS PS PS
U U U
6) Restrictive Horizons Q
� v
7) Available Space S S S
IS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification . 5
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
At
DCHD(6-82)