1545 Davie Academy Rd Y>
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
a Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)--- j. Permit Number
Name Date (irk!
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size __ House Mobile Home _ — Business Speculation
No. Bedrooms No. Baths _ — No. in Family Z
Garbage Disposal YES F] NO �y Specifications for System:
Auto Dish Washer YESNO
Auto Wash Machine YES [� NO
Type Water Supply ZZ
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
y' Improvements permit bye
*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 - �
N
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.
r
..'. 4 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 MrCEIVED FEB 1 1
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 6 3,Y-. Sul
1. Permit Requested ByPSA earfncr Business Phone -4,3µ- SIMS
2. Address PO Box 96 Mocks vi f lc� , NC 270.28
3. Property Owner if Different than Above Roy Cmr trier
Address PQ /3ox 90 MocksyillG , NC a7oa9
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional Other Type—
Ground,
ypeGround Absorption
c) Sub-Division Sec. Lot No.-
5.
o.5. System used to serve what type facility: House I- Mobile Home Business
Industry Other—
b)
ther b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions .29, x 4o
Bed Rooms-3._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 1
dishwasher sinks 1
8. a) Type water supply: Public_K Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 5 a�rr_s
b) Land area designated to building site
c) Sewage Disposal Contractor myself
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? no
What type?
This is to certify that the information is correct to the best of my knowledge.
aJ Q 18 8 �. -/Z C
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
(a4 w 4v Carfhers • skrc - Ldf-f on]v DA'vie Rcadermjr Rd. - Crass over I-46
opproximaieky a miles. Poor Boys Road on Lei+. P
424+ Cecit CQr+hers on
right- -T-urn ri jh+ on pri va+e dri ve a+ *obacco born . Co Pas+ on04-her
-6bo.ex-o born on the Privafc drive . Building 6i4e is opprouimaid
300 T+. posh- born or, jet+,
Gca�orcL Lumber Co, and T II
Cad 1 90 w 4h Yau. 34- 5148
DCHD(6-82) __
---t DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionS S S
(A' U PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
U n U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PSS PS
(0 d5 U
4) Soil Depth (inches) S S S
PSPS PS
U U
5) Soil Drainage: Internal S S S
PS
TU5 U U
External }�� S
`--U PS
6) Restrictive Horizons /t ii
7) Available Space S S
PS �
is PS
U U
8) Other (Specify) S S S S
PS PS PS PS
U / /U U U
9) Site Classification , S, -
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �/ Title �� Date
SITE DIAGRA
� 2
UCHD 0.87