1167 Hwy 801N (2) M 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
L��! '+r'; Date
Name
Location , -ter
Subdivision Name Lot No. Sec. or Block No.
Lot Size L House Mobile H1ome'/� Business Speculation '
,No. Bedrooms No. Baths
c2 _ No. in Family��_. -t -•
Garbage Disposal YES ❑ NO Q
Auto Dish Washer YES NO ❑ Specifications f� stem: ,
Auto Wash Machine YES, g NO ❑
Type Water Supply _
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
r. .
1
_ ._._.......
P
y 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
�rJ
Certificate of Completion "-' Date � �' n �'
*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.
JUL o
1986 ,
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 BEEN ISSUED.
Home Phone
1. Permit Requested By M Business Phone 7qq- 00A9
2. Address ) Ir # a- rS'fi jtm ,-.d a7 fc At/, /!�C'. g 7 .7-
f�
3. Property Owner if Different than Above for ;o o T Q JPd
Address e t*?'i Tory SYADyj'LLE i4 E ,EL S.' an/
4. Permit To: a) Install Ix Alter Repair
b) Privy Conventionalj,:!�'_Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House-iCMobile Home Business
IndustryOther �Ru�
b) Number of people y
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /!j s. �n OR DduRls-W i 0�
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)
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-1:�Au,E
b) Has the water supply system been approved? Yes'—' No
9. a) Property Dimensions / L3 Lf Aegys
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.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR OMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�., wA y 7dw inozbs11 w:1, <« �S A TEQF�'�!�
IV At P OpE47y� YI
DCHD(6-82)
�D I
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION /
NameDate
Address Lot Sizes/��
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionS S
�-�
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) l PS
P,�
U 4' U
-5
3) Soil Structure (12-36 in.) $ S S
Clayey Soils P�j�9 Ps- PS
`-Q U N�
4) Soil Depth (inches) yySS��,, S S
(PSS PS PS
5) Soil Drainage: Internal S S
S
OU
P
U
External S S
p Z7" P PS
6) Restrictive Horizons
7) Available Space
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U Un U
9) Site Classification , , `/.� • v.
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
IW
Recommendations/Comments:
Described by Title w Date
SI E'D GRAM
1
DCHD(6-82)