P5271 Davie Academy Rd Yv A Y ✓✓✓
DAVIE COUNTY HEALTH DEPARTMENT
¢. ' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c #
j Sewage Treatmen and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name--' �C flr' e -71
ll" ��i'ZZ ���9�,rISG � / � � N �2
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size, House Mobile Home Business Speculation
No.-Bedrooms !C7_ No. Baths No. in Family
Garbage Disposal YES 0 .NO p'" Specifications for System: /- U
Auto Dish Washer YES NO p �, cam'-- P}�,
Auto Wash.fvlachihe YES [ NO p
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
,I
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 com ion—Teleph umber: 704-634-5985.
Final Installation Diagram: S,y�st9m Installed `
i6a
1i
oma___,_„
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER IT l�
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS
77 BEEN ISSUED.
Home Phone
1. Permit Requested By 16dewe & 1 Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-ZAlter 1 Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot NQ,_
5. System used to serve what type facility: House Mobile Homer Business
IndustryOther
b) Number of people
6. a7 If house or mobile home, state size of home and number of rooms.
House Dimensions a
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 Privatey Community
b) Has the water supply system been approved? Yes No—Z
9. a) Property Dimensions RDO aas_e'4
b) Land area designated to building site a-11
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? ?
What type?
7 T/his is to certify that the information is correct to the best of my knowledge.
L (y 4� c
Date Own e gnature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: /f LfI
DCHD(6-82)
1
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' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
R O. Box 665
Mocksville, N.C. 27028
/ SOIL/SITE EVALUATION
Name f Date ?AV 1f
Address Lot Size � 1�n
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
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
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S
VS PS
PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S S
P PS PS PS
U U U
6) Restrictive Horizons
7) Available Space 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 '
U—UNSUITABLE S—SUITABLE �_S—Provisionally Suitable
Recommendations/Comments:
Described by Title �/�/V Date
SITE DIAGRAM
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VCHD(6-82)