1781 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 Treatmennd Di sal Rules (10 NCAC 10A .1934-.1968) Permit Number
r
Name �%%� Date 32,19
32,19
el
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size �'' House �� Mobile Home _ Business Speculation
No. Bedrooms No. Baths — / _ No. in Family
Garbage Disposal YES ❑ NO Ej- Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES p ^ NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
- ----------
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
04-634-5985.Final Installation Diagram: System I stalle by �
Certificate of Completion Dat
7—
'The signing of this certificate shall indicate that the system descri ed 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
R 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
PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) fjN-� PS PS
U U U U 1
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS
U `T� U U
4) Soil Depth (inches) � S S
PS S PS PS
U U U U
5) Soil Drainage: Internal g� � S S
C� PS PS
U U U U
External � S S
c��-� PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S S
PS 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
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by t' Title : Date
SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ,43
Davie County Health Department 2i
Environmental Health Section ,3�
P. 0. Box 665 '
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
A, Home Phone 1/1 f– V6 7 0
1. Permit Requested By Q k �l,Ns��� (.�•�Md Business Phone
2. Address _Ro��fe 3 aoY_ 5 to c ksv i DIVA 77 < : 7 o 2 J
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Iter Repair
b) Privy Conventional tether Type
Ground Absorption
c) Sub-Division 414 Sec. Lot No.
5. System used to serve what type facility: HouseHome—- Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 3o ' X �/0
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 U washing machine
dishwasher 4 sinks /
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes t�No
9. a) Property Dimensions
b) Land area designated to building site w
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? �d
What type?
This is to certify that the information is correct to the best�ofmy nowledge.
Date Owner Sig a ure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
d ; � o w/ovv_ /a e.e /coo �Gl �je rs�:� �r7' 11"4ax c a AXe__-
2,4
DCHD(6.82)