1168 Junction Rd DAVIE• COUNTY HEALTH DEPARTMENT -:
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION yy
"NO.TE:. Issued in Compliance witfilG.S: of North Carolina Chapter 130 Article 13c 1�
M ,per
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-..1968) Permit NumbeY
Name Datei 4
Location'
Subdivision Name l Lot No. Sec. or Block'No.
Lot •'Size. Housii e Mobile_Home ' Business .Speculation
No. Bedrooms -_ No. Baths No. in Family 3
Garbage Disposal. YES.0 . NO Specifications for System:
Auto Dish Washer YES •NO p
Auto Wash Machine YES•®!. NO.
3 Q x , a k
Type Water Supply
"This'permit Void:if sewage system idescribed below is not installed within.,36 months from date of issue.
1I. 'Improvements permit by \_\
1
'Contact a representative of the Davie County Health Department for.final inspection of this. system between 8:30-
9:30'.A.M.
:30-9:30.A.M. or 1:00-1:30 -P.M. on dayl�of;-completion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
vo
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 Junction
satisfactorily for any given period of.time" .
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department '
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS B�UER, N;
/ / Home Phone
1. Permit Requested By rl�o"tYr✓ �— r�;f�� Business Phone
2. Address f) -.,I 15�Z
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 s
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions—1 V X 66
Bed Rooms—Bath Rooms Z-- 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 No
9. a) Property Dimensions d z!Y- '
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.
.2 -9- 92 - 41's,
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section 1•
P. O. Box 665 '
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name � d W � '� � �o�d c 1C�`� `t.1 Date
Address �s� 1 C�rv��a Li - Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
CT <3!ff> kps-S PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) ( PS PS
U U Qr-D U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils �-D PS US
U
4) Soil Depth (inches) tS
PS
U } U. U U
5) Soil Drainage: Internal S S S
C::� PS
U U U U
External S S
P � _ PS
U U U U
6) Restrictive Horizons
7) Available Space
S
PS C-51) C PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
\4�-S 1 �3-
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by � 1 Title Date D
SITE DIAGRAM
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Ni '
R
DCHD(8-82)