1028 Joe Rd -106
.. DAVIE, COUNTY HEALTH. DEPARTMENT
{i IMPROVEMENTS PERMIT AND CERTIFICATE 'OF COMPLETION -`
IFN 0TE: issue' m Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment.and Disposal Rules (10 NCAC 10A .1934-.1968) Permlt NUmbef
Name •ICj 3869
' Location - ''/.;fes _. -j /"i ✓ r.i c'" Y:
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Subdivision Name Lot'No. Sec. or Block No.
Lot House 4��I;�4M61bile Home _ ' Business Speculation
r
No. .Bedrooms No. Baths,._&- .;No. in Family; _
Garbage Disposal YES : NO 2--
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES � NO
Type Water,.-Supply X., o
*This Spermit��Void if'`sewage system described_below',is;not installed within.36 months from date of issue.
I{- -ti--
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
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All
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-.^A s., ':1W < � a4d� �-Kffl tir'"�3 ga I � l - .. .• -
`= C6dificate'of Co'mpleti \
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#The signing of this certificate shall,indidate that the system'described above has"been :installedtih compliance,with'':
the standards set forth`in theiabove-regulation, but shall in NO way be taken_as a guarantee,that the yste.m will function
satisfactorily'for any given period of time. ':
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 3•�
r Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By A\. uo_"a iL Business Phone
2. Address 11A. rc 2,7c,,(.
3. Property Owner if Different than Above
Address
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
IndustryOther
b) Number of people T
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms I �� 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 Pr rate Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions t 0-CA4—
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?
What type?
This is to certify that the information is corre the best 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:
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ZAW-11k-e2e Date ��' e
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S S
PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, }-� S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
(� U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS PS
U U
4) Soil Depth (inches) � S S
PS PS
U U U
5) Soil Drainage: Internal SS S
PS PS
U �� U U
External S S S S
PS PS 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 C!-Provisionally Suitable
Recommendations/Comments:
Described by Title T� Date
SITE DIAGRAM
49
J
DCHD(6-82)