168 Papoose Trail r DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name Date
Location –.1�. /✓t I fel,i�(,Gi ir% "�% /V; ! J�.:� _
Subdivision Name Lot No. Sec. or Block No.
Lot Size r, House `''� Mobile Home _ Business Speculation
No. Bedrooms ' No. Baths No. in Family
Garbage Disposal YES ❑ NO Specifications,for System:
Auto Dish Washer YES ❑]NO,
,�-
Auto Wash Machine YES 4:) NO ❑ ,
Type Water Supply - j _—
*This permit Void if sewage system described below is not installed within 36 months from date;of jssue.
j ;l�✓,1
i
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 byf
i
r'
Certificate of Completion alt `� I Dae
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*The signing of this certificate shall indicate that the system described ab Q1ve has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken las 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— � �„�'� �P7 Date
Address ��l/%�<✓ �l�f Lot Size—
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position � CJE� (i> 0
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) �P3S1� PS PS
U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils_ PS � �
4) Soil Depth (inches) S S S S
PS PS PS PS
5) Soil Drainage: Internal S S S S
PS PS PS PSU
External -=S
PS PS PS PS
U U U U
6) Restrictive Horizons /� �• �� � ' `� ,, /� �,
7) Available Space
S 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: j - U S I eL-
Described by / Title ��� �� Date
SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 9Q8-�y0 9
1. Permit Requested By Z Business Phone
2. Address ,?r adf .fJOX at5�cs" 190111Z I-1- ,V. e. W�a�G
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-ZAlter Repair
b) Privy Conventional Other 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 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions ���X e
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 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 7" 'X 7"
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? /V4
What type?
This is to certify that the information is correct to the best of my knowledge.
Dat6 Owner S1996ture
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE.WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
JJ
• 1
DCHD(6-82)