P5000 Davie Academy Rd ` J.._J ..j• :;7
ot DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
a�e (6 1 q
NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c ,
Sewage Treatment and Disposal Rules (10-NCAC 10A .1943i4-.1968) Permit Number
Name Dates3 a '10
I
J
Location \"'A
C}_� r'p•':-S`^r �. � �;V.-+� c'�•...� ?-..� eSubdivision
�
c Name Lot No � S . or BlockNo.
Lot Size , House Mobile Home _ i Business Speculation
No. Bedrooms _ No. Baths �' No. in Family '_—
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES [.. NO ❑ _ t
Type Water Supply
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit bye ,
"Contact a representative of the avie ounty Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. o day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by v t
Certificate of Com letion ��%�� 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 'L3
Ov / o
Davie County Health Department O D 0
Environmental Health Section a
✓� R O. Box 665 ` �►
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone '"
1. Permit Requested By e-d r/c Business Phone
2. Address G�
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 P Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size ofhome and number of rooms.
House Dimensions o ,
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 Noy
9. a) Property Dimensions fi(2/'"
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 thebest o my knowledge.
Y_ � ` �� ,
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
A_ >,X I�CO
Af-
ail
DCHD(6-82) -
DAVIE COUNTY HEALTH DEPARTMENT �.
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION �j
Name "' . Date �—�V� /
Address _ -ltiicn�!t 9 Lot Size �::I.
FACTORS AR19 AR6>2- AREA 3 AREA 4
1) Topography/Landscape Position —Zilp PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) C -Ps-� `RS-� PS PS
—}�—' U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils P PS PS
U U U
4) Soil Depth (inches) S S
&> PS PS
U U U
5) Soil Drainage: Internal Sr � S S
PS PS
U U U U
External S S
PS PS PS
U U
6) Restrictive Horizons �))
7) Available Space S S S
g PS PS PS
U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification �j S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by
�� Y-�"� Title Date
SITE DIAGRAM
-�2
DCHD(6.82)