341 Little Egypt Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
f- 1
= ..-. 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
Name s '--s- �=/r' f-'J�s� %i ;Date ZL21-e �1EEL �ro::;ca
— � ,✓ sem:�
Location 0"
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business __ Speculation
No. Bedrooms -- No. Baths No. in Family_ _ -5-
Garbage Disposal YES NO ❑
`Specifications for System: �
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
Name /�S Date
Address Lot Size /l• �S CYC
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U 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 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
pg PS PS PS
U U U
6) Restrictive Horizons
7) Available Space �S 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 . S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by / Title Date
SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 0Cj ® 1 �'�
Davie County Health Department -1
Environmental Health Section
P. 0. Box 665 ��,__
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PE
,ERMItTAS BEENeIS$UE(
C °r Ho Phone �r 3 -c 5 3
1. Permit Requested By O Iti�r�� � � - Business Phone
2. Address
3. Property Owner if Different than Above ), �/92 7233
Address
4. Permit To: a) Install � Alter Repair
b) Privy Conventional '-I Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House 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 /y k 76 1.
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) Jf,
7. Number and type of water-using fixtures:
commodes urinals garbage disposal j
lavatory � showers :)- washing machine i
dishwasher sinks _3
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property'Dimensions -3 R
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.
ao �, �� -
Date Owner Signa re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCELH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: rot
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DCHD(6-82)