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- N DAVIE COUNTY HEALTH DEPARTMENT
- _ IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION L*4 y,�J
„ *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
Name �:, / n; 2
Location _
Subdivision Name Lot NoSec(or Block No.
Lot Size ' L _ House Mobile Home _�r Business Speculation
No. Bedrooms No. Baths _ No. in Family _
Garbage Disposal YES :p NO
Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Machine YES p NO ❑ `^ ;I
Type Water Supply -V%.)
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
F
Certificate of Completion ,\ fb 3- 30�-q 1q
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. r
1
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT Dai
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.
Home Phone C' �t�4
1. Permit Re uest d y
OT e✓ �4,C'max Business PhoneC��p� 7
2. Address s
3. Property Owner ij Different than Above
Address 7
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 Other
b) Number of people 12
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions�'Ld�s
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 t/ 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 � 0.c&
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? /l/dyle
What type?
This is to certify that the information is correct to the best f my knowledge.
-2yf2
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
A6r �� .rte q7,4
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DCHD(6-62)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name I'r'e` Date_
Address Lot Size LA
FACTORS AR 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionS S S
PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) P S PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils P PS PS PS
U U U
4) Soil Depth (inches) S S S
PS � PS PS
U U U
5) Soil Drainage: Internal S , S S S
r jiPS PS
U U U
External SS S
PS � PS PS
U U U
6) Restrictive Horizons
7) Available SpaceS S S
p� PP PS PS
U U11 U U
8) Other (Specify) S S S
PS PS
U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS— iy Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
ED1
DCHD(6.82)