759 Junction Rd Y' _ r — ..-.� ...,......yw...-....o. --,vtiz. :-�+rlb t... :....,. .fir- c:s r•-W.:.:..•W+w•.--u..oa:,:sFas+-"--"- - - - ,. ;t7rA-.ri
DAVIE COUNTY HEALTH DEPARTMENT J
IMPROVEMENTS PERMIT AND CERbFUCATE 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
Date 5004
Location " -tom„ T -L-A1 m�i��C .,M
14 1k
Subdivision Name NSe_c 'or=6lock No.
Lot-Size- -- House �,I Mobile Home —✓ Business __ Speculation
No. Bedrooms No. Baths. f ;No. in Family
rl
Garbage Disposal YES NO p: i Specifications for System:
A .
Auto Dish Washer YES ❑ NO 0 !I ) L�
'Auto Wash Machines _ YES ❑ NO ❑
Type. Water Supply -- r
`This permit Void if sewage system,described below is not installed within 36 months from date of issue.
I
,`� ° .. ISI •_
Ij Improvements,permit by `w.�. . .. r.. , .�`•_,_
'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: 7041634-5985.
Final Installation Diagram: System Iristalled by
• . . tilt' , ,
it
i
1,
• - ,'SII �� � � � ,
Certificatelp
of'Corh letion Date
"The'signing of.this certificate shall indicate that ttie 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. �f '
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department O�C
Environmental Health Section {
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone /� 3
1. Permit Reque ted By �– Business Phone
r
2. Address 'Z–
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: House Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions l40 x ��
Bed Rooms Bath Rooms_t 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—
b)
imensions 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 correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allo 5 da s for processing
/
Directions to prop y: –�
J
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
- SOIL/SITE EVALUATION
Name \'C7Date
Address "Q'\e Lot Size :s-
FACTORS
FACTORS ARE 1 ARE 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) —7P PS PS
U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS
U U
4) Soil Depth (inches) S S
PS PS PS PS
U U
5) Soil Drainage: Internal S S S
d F17 U PS
U U U
External S S S
PS PS PS
U U
6) Restrictive Horizons
7) Available Space S S S S
/:P3"'� PS PS
`--t�-� U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE Provisionally Suitable
Recommendations/Comments:
Described by ` �i� - Title =1 Date _1
SITE DIAGRAM
a
F
DCHD(6.82)