235 Baltimore Rd +k.= DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE 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
Name Wil, ,, ; Date 3G!
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size ?{%`> House Mobile Home _ lv Business Speculation
No. Bedrooms No. Baths ' No. in Family
Garbage Disposal YES ❑ NO E] " Specifications for System:
Auto Dish Washer YES E] NO ❑
Auto Wash Machine YES p NO -❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
t
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 -
1
i'
r
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 O. Box 665 ,
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date ��
Address Lot Size �D
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S-.� S S S
Loamy, Clayey, (note 2:1 Clay) �� PS PS PS
U U U U
3) Soil Structure (12-36 in.) S . S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
47 PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS 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
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—Provisionali
Recommendations/Comments:
Described by Title / Date y
SITE DIAGRAM
/ T 1
VCHD(6-82)
APPLICATION FOR SITE EVALUATIO�wiMPH,.. VEMI NTS PERMt �
Davie County Health D,?hertment ,
Envi(onmental I-lealrh Sec-don
P. 0. 1k)x 665
A4ocksvills, N.C. 27023
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS MFN ISWEII
Home rgone
1. mit Requested Business Phos
2. Address -----•--- ---
& Property Owner n Dillerent than Above -_—_--�—
_ Address
4. Permit To: a) Install. Atter Repair_— Po. S
b) Privy Conventional✓Other Type___
1
(around Absorption ag
c) Sub-Division__-__ _ Sec.---_..—Lot No:
!3. System used to serve what type facility: House,_..Mobile Horne Elusiness-__
Industry_—Other___
b) Number of people—
a)
eople a)If 1101LIS or mobile home,state size of home and number M rooms.
House Dimensions�,L _—__—
Bad Rooms—Bath Rooms_.__Den w/Closet. ._
b) If Business, Industry or Other, State: Number of persoiis. served —
What type business,etc.._ �..�.—..,._-----•-.—_-- -- _ -
Estimate amount of waste dally (2-4 hours)—___.-
7.
ours)__.- _.—_.._7. Number and,type of witer-using fixtures:
commAes—._2--_. urinals—_—_--_ garbage disposal r_
lavatory ;2,_—___ showers washing machine—
dishwasber f sinks _.._—_..—_....
& a)Type water supply: Public_`__F'rivaje_-____Cummunity—.
b) Has the water supply system been approved? Yea✓✓No_.-
9. a) Property,Dimensions-1 _.---- ---
b) Land area designated to building site
c) Sewage Disposal Contractor_LfA_X_21 ----
10. Do you anticipate any additions or expansions o he facility tris sewatle system is intended to serve?
What type? ----
___ This Is to cortify that the information is correct to tho best of my knowledge.
_tea P'_- _L _a.�
ate Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPL1AN; E WITH ALL STATE AND LOCAL LA
VVS
Allow 5 days for processing
Directions to property:
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FOR DAMES B. PRUITT-CATHERINE K.
SCALE• -TOWNSHIP• -COUNTY- -STATE- -DATE TK-
CERTIFY
=40' FARMINGTON DAVIE N.C. 16-2O-'!_85
"�1,/CERTIFY THAT ON 2� ,
18J0., , WE SURVEYED THE PROPERTY SHOWN ON
THIS PLATt
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•- SURVEYEDt
FRANCIS B.GREENE JOB No.
. ... MAPPED: SURVEYING AND MAPPING CO.
.r P.O.BOX 501 MOCKSVILLE,N.C.
27020
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