256 Deadmon Rd .... ...:.. ..
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 '1' 14 ,r ��„y. Date —/ � 15 Np d
,,_ _
Location
d
Subdivision NamJCe� Lot No. Sec. or Block No.
Lot SizeHouse Mobile Home � Business Speculation
No. Bedrooms No. Baths C22� _ No. in Family
Garbage Disposal YES ❑ NO
Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES NO ❑ �` G`��_,f �1
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by �” 2
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
A.M. or 1:00-1:30 P.M. on day of.completion, elep one N tuber: 704-634-5985.
Final Installation Diagram: ystem nstalled by 6 =Y>i'/'�� !1�'tGf ' a
I
1
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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.
tw APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT NCO
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
0
1. Permit Re a ed B �V4I)V1 V0'n+tVrla G
on �70�
2. Address ! y V40("v 1 1167
3. Property Or if Diffe nt than Above Ma e Q�
Address 0 �-�
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—IndustryOther
b) Number of people
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions 28 x52-
Bed Rooms Bath Rooms' Z 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 ofxvater-using fixtures:
commodes a urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public PrivateCommunit
b) Has the water supply system been approved? YesNo17
9. a) Property Dimensions �SD� X 76o` CQ-q ae,e ES 11'L a
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? A/6
What type?
This is to certify that the information is corr to the best of m wledge.
Date Owner gignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82)
a> DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �����/ Date
Address Lot Size '2
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) % 5 PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) J S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
- PS PS PS
Lj J/ U U U
External S S S
pS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space 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 ����� Title .5 N -- Date �l✓ ��
SITE DIAGRAM
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OCHD(6-82)