1577 Davie Academy Rd DAVIE COUNTY' HEALTH DEPARTMENT
L IMPROVEMENTS PERMIT AND', CERTIFICATE OF COMPLETION i
}. NOTE:. Issued in-Compliance with G.S. of North Carolina Chapter 130 Article 13c '+
Sewage Treatment sand Disposal Rules (10 �1 1968) Permit .Number
pp _ vkc<,
Name ., e C 11 rj iDate 21,„ .1,L4460
I ',
�
Location I[ e �It cam._ ' ``
Subdivision Name " Ilr Lot No. ,'I Sec. or Block No.
,
Lot Size L&W k. ren +� II House V• Mobile Home �-- Business Speculation
t, l
No. Bedrooms _ No.11Baths `""No. irriFamily
Garbage Disposal YES�E NO 1W�
Specifications for System:
."Auto Dish Washer YES �! NO ❑ ; . _
'Auto Wash Machine YES NO
If ,� ejA X
Type. Water Supply --
�I
;'This permit Void if sewagefsystem described.below is not installed within 36 months from date of issue.
• , ; . �� yds ,;
Improvements permit by
*Contact a representative ofthe6vie County Health Departmentli for final inspection, of this system between 8:30-
430-A.U. or 1:00-1:30 P.M. ,onll day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: ` . - � p\' System installed by
G_
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 above1'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
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/� Home Phone
1. Permit Request By C ' �`�,%�� Business Phone
2. Address - Q
3. Property Owner if Different than Above
Address
4. Permit To: a) Instal Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division S Lot No.
5. System used to serve what type facility: House,?Mobile Home Business
Industry Other
b) Number of people ��
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms -F 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 �L_ urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private 'r Communit
b) Has the water supply system been approved? Yes-
9.
es 9. a) Property Dimensions X 00
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?
What type?
This is to certify that the information is correct to the best of knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
01
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �-`� C�Jd�y�C�� Date
Address 1 �b Lot Size ba x aVF
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position d S S S
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U U
4) Soil Depth (inches) S S S S .
-- pS PS PS PS
U U U U
5) Soil Drainage: Internal S S S
PS PS PS PS
U U U
External S S S
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
9) Site Classification,
U—UNSUITABLE —SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by_��? `^ Title Date V
SITE DIAGRAM
CY
DCHD(6-82)
pavie Qlou Ttg Peulf4 Department
nub Monte Men1t4 �Senq
P. O. BOX 665
,larksuille, �qart4 Carolina 27028
OFFICE OF THE DIRECTOR - TELEPHONE
June 10, 1987 (7041 834.5983
Howard Realty
330 S. Salisbury St.
Mocksville, NC 27028
Attn: Julia Howard
Re: Sewage Disposal Installation
Rick Daywalt Residence
Dear Realtor:
The septic system was installed at the aforementioned address
on June 1, 1987 . At the time of installation, the system met
the requirements of the North Carolina sewage disposal laws. As
of this date, the househas not been occupied. Therefore, the system
can be expected to function as designed.
Sincerely,
Charlie Little, R.S.
Environmental Health
CL/wd