134 Livengood Rd DAVIE COUNTY HEALTH DEPARTMENT]
k IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
,*,NOTE: Issued in t✓o4pliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
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� V
Name�'* � '— �� � ��� Date
Location �'-., .� /%, ,✓�/ ✓,? p ✓ n1�_. /moi/"% ,r,� 'i✓ , r� 1:5
i�
yr 6Q �_.
Subdivision Name t o. Sec. or Block No.
Lot Size ��� e2 House Mobile Home _ Business __ Speculation
No. Bedrooms `– No. Baths 4 No. in Family
Garbage Disposal YES p NO g---
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO
Type Water Supply li'/�/ -- v%"•�`ii"y
'This permit Void if sewage system described below is not-i6stalled,within.3(5months from date of issue.
L. I �
,
Improvements permit by`— -,- �•,
*Contact a,-representative of the Davie County Health Departmenifor final inspection of this system between 8:30-
9:30-:X-M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
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Final Installation Diagram: System Installed by
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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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name P Date
Address Lot Size���Je�9
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, � � S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils ® PS PS
U U U
4) Soil Depth (inches) ( S S
' C5 PS PS
U U U U
5) Soil Drainage: Internal S S S S
<29D -15PS PS
U
U U U
External S® S S S
PS PS
U U U
6) Restrictive Horizons
7) Available Space S S. S S
c� 1 J""' PS PS
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 Date
SITE DIAGRAM
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DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section ,
r P. 0. Box 665 V(
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
---r� Home Phone 19'd- -Aw)I
1. Permit Requested By Business Phone »h'q 103
2. Address R , 9, gox X16R %a R, , C1®Q, a>Ooh
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 S c. Lot No.�g
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions vllr x 3$
Bed Rooms—Bath Rooms_Den w/Closet 1
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 2 washing machine 1
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 R�v
b) Land area designated to building site rids
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /VO
What type?
This is to certify that the information is correct to the best of my knowledge.
d
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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on Chug& RdA
Dight on 1.Villio-m6 R4
{lrl�,bi le flame, on 810111t -
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3 Gy
Fick Ch�r4h (fid,
DCHD(6-82)