2408 Hwy 158 (2)DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c. `
Permit Number
Name 111s'Fi,yi c Date �"
Location /S~ ! i lav ; � lr�+",�;.� c;�• �,r U ,CSG -
Subdivision Name
Lot Size
No. Bedrooms
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply —
*This permit Void if sew(
Clime(. t 4/
-House
No. Baths
YES ❑ NO 0
YES ❑ NO
YES ❑ NO C❑
e0 WJ -T `/
Lot No. Sec. or Block No
Mobile Home _ Business Speculation
No. in Family
Specifications for System:/000,96/41.11,,L,
T"71
)w is not installed within 36 months from date of issue.
1
s
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, " I /
Certificate of Completion Zx�Date `
1.
*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.
` APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT << q-z�-YZ
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERy,IT HASPEEN ISSUED.N"`"""''
ISh�Ph�llB
-Tn[ �l�V Home Phone ���' 7'7/1. Permit Requested By D�2 �/�/�7`�5 _ r4r/1 X1e_ Business Phone
2..Address
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 Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people U
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 Z
8. a) Type water supply: Public_ Private Conity
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions SpL•
b) Land area designated to building site M O I x 6 d l
c) Sewage Disposal Contractor �/
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /'' O
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 'A NCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
• DAVIE COUNTY HEALTH DEPARTMENT C 1 Z
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 14o PE ;9APT/S-r TA9&ZyA GLS Date "ZZ—Tr 2—
Address
Address Lot Size!! Ate'
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S lJ 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 A P PS PS
U Q U U U
3) Soil Structure (12-36 in.) S v S S S
Clayey Soils PS L, P PS PS
U 1 U U
4) Soil Depth (inches) S S S S
PS � PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U 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 PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
QU—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comme
Described by 'S/P£�4S Title �N/TA�iAN Date
SITE DIAGRAM
DCHD(6-82)