P5135 Davie Academy Rd DAVIE COUNTY HEALTH DEPARTMENT
j IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Issued-in Compliance with G.S..of North Carolna,Chapter 130 Article. 13c
wNASewage'Treatment and Disposal Rules.(10 NCAC 10A .1934-.1968) Permit' Number
Name ///1: /%'� ��/��G' �� >>.,'��i' i Date MG 5135
°ter
Location /r.. .r` //"�✓' / t//i�i/' r /�r" � — /�%kr / tYJ m%' ,f`�/
Subdivision Name Lot No. Sec: or Block No.
Lot Size W46Y 1'Tr7' House ` Mobile�;Home _� Business Speculation
I
No. Bedrooms ' No, Baths _ No. in'Family .�
,
Garbage-Disposal YES .❑ ',No ii• Specifications for,System:
Auto Dish Washer YES ,E] NO .
Auto.Wash Machine YES ElN0
Type,Water.'Supply
—
*This'permit Void if sev✓age system described'below is`not installed within 36 months from-date of issue.
' ,.• it .�_ '
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\ •v
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 betaken as a guarantee that the system will,function
satisfactorily for any given period of time. .
`j APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
U Davie County Health Department R 3 0
Environmental Health Section c v�O.MA
P. 0. Box 665G``
VO Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested B 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,4:n'_Business
Industry Other
b) Number of people J
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)
Number and type of water-using fixtures:
l commodes urinals garbage disposal
l lavatory ___? showers Z washing machine
dishwasher sinks -/
8. a) Type water supply: Public G Private-Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions .�o
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 my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
dos
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age--
15-7
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Hearth Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name /�! � Date
Address Lot Size /&dc;
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
U" 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
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils (ff§) PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
t) PS PS PS
U U U U
External S S S
d' PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
`b PS PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification R ,
U—UNSUITABLE S—SUITABLE PS Provisionally Suitable
Recommendations/Comments:
Described by Title , � Date100,
SITE DIAGRAM
�j
DCHD(6.82)