2890 Hwy 158 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-.1968). Permit ,Number,
Named ? �� —'� � �;; Date t� ,Z� " `. . ' �;f 40-36
r/1v!✓E
Location
Subdivision Name - Lot No.. Sec. or Block No.
Lot Size a House Mobile Home Business __ Speculation
'No._Bedrooms No. Baths:( No: inTFamily
Garbage Disposal YES.O NO go'' Specifications for.System:
-Auto Dish Washer YES:q NO p4Db ',f
Auto Wash Machine YES NO p • �J r
Type Water Supply, -- "1�eol
X S,X/,;�
"This permit Void if sewage system described below Js not 'installed within-36. months from date of issue.
Ar
1
c; 141 �...
Improvements permit by
*Contact a representative of the DavieCounty"Health Department for final inspection:.,of this system between 8:30-
A.M. or 1:00-1:30 P.M. on. day 'of completion.-,Telephone Number: 704-634-5985.
Final Installation,Diagram: System Installed by
t ;yr
Certificate of Completion Date '
The signing of this certificate shall indicate that the system described above..has been installed in compliance with
thelstandards 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.
t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department z4p���
Environmental Health Section �G
R0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.G
Home Phone
1. Permit Reque ed B maa i Business Phone
2. Address ' C
3. Property Owner if Differenj than Above Y, Q
Address 0
4. Permit To: a) Install Alter Repair
b) Privy Conventional kf!�`6ther Type
Ground Absorption
c) Sub-Division Sec. Lot N
5. System used to serve what type facility: House o.Mobile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Iq / X 26 /
Bed Rooms—�9- Bath Rooms 2 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 1
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No__ )o� G' cAn?&I on
9. a) Property Dimensions�� y•)D a// T' Q7d,
b) Land area designated to building site /
C) Sewage Disposal Contractor �� 110-r nd any �
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 Lnowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: 4
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oh�Y b� �O er f
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date/ZS —
Address Lot Size Z
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS ,PS PS PS
Ul U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) -S US US
3) Soil Structure (12-36 in.) S S S S
Clayey Soils P PS PS PS
U U U
4) Soil Depth (inches) S S S S
g. . PS PS PS PS
U U
y '
5) Soil Drainage: Internal S S S S
PSP PS PS
A, U U
External S S S S
P PS PS
4 U U
6) Restrictive Horizons r,,, 0
7) Available Space S S
(` PS PS
VSI
U
U U
8) Other (Specify) S S S S
PS PS PS PS
U �UU U
9) Site Classification C//. 1 (/1 /
S -
U—UNSUITABLE _ S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described byTitle iTl/ Date
SITE DIAGRAM
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6
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1
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DCHD(6-82)