597 Becktown Rd DAVIE COUNTY HEALTH DEPARTMENT
-- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934/.19 8) Permit Number
Name _ /: . »�='�� f Date (1/ N2 5606
Location .
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES p NO Q� Specifications for Syste
Auto Dish Washer YES NO fl
Auto Wash Machine YES g NO
V
Type Water Supply /.fi"! ' _ 0✓ mit�J` �,�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
r
Improvements permit by Ala,
*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
i
F
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.
M
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS. PERMIT
Davie County Health Department
l q ` Environmental Health Section RECEIVED J U N O Z 09
n, P. 0. Box 665
Mocksville, N.C. 27028
s
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone qq ` WP`63
1. Permit Req sted By 'in '15 I Qk)5 Business Phone
2. Address
3. Property O ner if Different than Above
Address 171 � 30,75- 1-11) c)(Lir'lI4e- /L) o? ?��
4. Permit To: a) Install_L�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 —Business—
Industry—
s
IndustryOther
b) Number of people PCZ C� r
6. a�If house or mobile home, state size of home and number of rooms.
House Dimensions �� l,es �kSZ� A• /I
Bed Rooms Bath Rooms Den w/Closet�L
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 2� - urinals garbage disposal
lavatory showers—sem! washing machine
dishwasher sinks kl ckti
8. a) Type water supply: Public Private Community
b) Has the water supply system been �o
approved? Yes -
9. a) Property Dimensions / � —
b) Land area designated to building site
c) Sewage Disposal Contractor U-1/1'?owti
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
E
This is to certify that the information is correct to the best of my knowledge.
Aajv M
Date wner Signature
i OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions�o property:
1 "Ro". t Lkr til 4'Q tqD Q tc --p ' _Lo
b e 5 I O / ho h
� �GOIt c� �e cn-r L � � ov,,cA Q.c& cam"-'
DCHD(6-82)
c
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
�f SOIL/SITE EVALUATION
Name �/ �]t�1' Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position (V 0 S,
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S
Loamy, Clayey, (note 2:1 Clay) <2P
U '( �j(�'�Y �P PS
3) Soil Structure (12-36 in.) S S S
Clayey SoilsY (� V
U '� tT
4) Soil Depth (inches) (A) SS (SS
U U U ZT
5) Soil Drainage: Internal S
U Ct'
External
P PS
C� U
6) Restrictive Horizons
7) Available Space S
PS PS PS S
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U . U
9) Site Classification IVJ 0-
U—UNSUITABLE
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by l � Title h Date
SITE DIAGRAM
DCHD(6-82) -