612 Becktown Rd,w.r-'-./�w..,v. ,y;�baa`:iY+�•rW+I+N"".yy4rnry!'n"•'—.wn�.^`'w".✓"...w."'."ti•.:wu• .m+,aijrY+.,-.dr.*r'lln+:..r�..r:+<s".*.."`^ir:s;vr"`'r\. f }.
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-.1 68) Permit Number
"\; '
J : b -%;- �+
Name 2 Date '3�
Location -;71 T/'..1 ,1 f;/�'.i,.;.�7_ i`�".\�` �" J'" �.'.i sem,. J ;71 ////,i?l;�
Subdivision Name Lot No. Sec. or Block No.
Lot Size it" — House Mobile Home _ 'r Business Speculation
No. Bedrooms No. Baths No. in Family ::"—:
Garbage Disposal YES ❑ NO E�-, Specifications for,System:
Auto Dish Washer YES g NO ❑ f' r � _
Auto Wash Machine YES NO ❑ % y
Type Water Supply � �� ---
*This permit Void if sewage system described bel is not installed within 36 months from date of issue.
7
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
i
v
s
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 PERMITflk PVA Z
Davie County Health Department G�0
J/ Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit RequesWd By 9Business Phone
2. Address y �lc1 0 A's I9>`,e L
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_AtffE�usiness
Industry Other
b) Number of people aJAQUGT 5 Chii..oxc,,J
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 'q(? 7K. 9 6
Bed Rooms Bath Rooms_Den w/Closet
b) If Business, Industry or Other, State: Number of persons serve
What type business, etc. yj 1A
It
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes 3 urinals garbage disposal
lavatory 3 showers ;2- washing machine
dishwasher I sinks 3
8. a) Type water supply: Public Private A"'-- Community
b) Has the water supply system been ap roved? Yes No
9. a) Property Dimensions l 173P
19C/L e s
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.
5 PC), L ��-
Date 6wner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: r
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DCHD(6-82)
•='v` DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name f '�<��� Date 1?,�//B
17
Address Lot Size !' �S�C
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
29>
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS 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
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
pS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
g PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
or ,
Recommendations/Comments: T
Described by — �� Title Date
SITE DIAGRAM
a,
P-1
DCHD(6-82)