2678 Farmington Rd DAVIE COUNTY HEALTH DEPARTMENT
4M 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 42 Date
Location 2
y
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _�-'"f Business Speculation
No. Bedrooms No. Baths — Z No. in Family—'��—
Garbage Disposal YES ❑ NO Q—' Specifications for System:
Auto Dish Washer YES , NO ❑
Auto Wash Machine YES $ NO ❑
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
_._..._._
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Improvements permit by
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
9:3p 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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j
Certificate of Completion Date e�,
*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
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION J /
Name & ,< Date
Address Lot Size nC• ����
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils (�r PS PS PS
U U U
4) Soil Depth (inches) S S S S
pg PS PS PS
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
6) Restrictive Horizons
7) Available Space 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 PS—Provisionali
Recommendations/Comments:
Described by Title �r�;!'/(� Date U
SITE DIAGRAM
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DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone ��
1. Permit Requested By cr e42 Business Phone
2. Address o v Al, C
3. Property Owner if Different than Above
Address
4. Permit To: a) Install--ZAlter Repair
b) Privy Conventional c' Other Type
Ground Absorption
0
c) Sub-Division Sec. Lot No
5. System used.to serve what type facility: House Mobile Homes
IndustryOther—
b)
ther b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 14 r .�6 7o�
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 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.
o 9. a) Property Dimensions 7S �
b) Land area designated to building site
c) Sewage Disposal Contractor jvoA,-&- e
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.
�- Z 2 F
T7
ate Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
'6
DCHD(6-82)