2621 Hwy 801N ?� 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
Name 44+rte �� .. ''�l Date
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 D- Specifications for System:
Auto Dish Washer YES NO p
Auto Wash Machine YES NO ❑ ,,/,/ 1
• �,;�t',_Cif/#'�tt."r' :`f�G<(,Y. � �C.:�F.i
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
l
Improvements permit by — �zLl .
*.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 stalled by
,1 U
�g
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 PERMIT l
nn /
Davie County Health Department r! o�9
Environmental Health Section
R 0. Box 665
Mocksville, N.C.27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN
�ISSUED. p
Home Phone ` q,t - 6o&o
1. Permit Requested By Business Phone —4
2. Address k O aS'
3. Property Owner if Different than Above
Address �{ �- ��o�'� /�-d,)�►uC_e �� 7D0(
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption whC�U 9eQJ-1
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business d
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms Den w/Close
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 oZ urinals garbage disposal
lavatory showers -Z washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
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 cor ect to t est of my knowled e.
0
Date canePature,,/
WNER IS OLELY RESPONSIBLE FOR COMPLIANCE WITH ALLTE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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J; p d)7 31-4
DCHD(6-82) -.
r y DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 1Tl Date
Address Lot Size SOIL°
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS �, PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
J (l U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils
PP PS PS
aU U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U
5) Soil Drainage: Internal S S S S
PS PS PS
--(9) U U U
External �S S S S
(om' P� PS PS
U U U U
6) Restrictive Horizons
7) Available SpaceS S
PS P5 PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITA E PS—Provisionally Suitable
Recommendations/Comments: -
Described by � �� '� Date
Title
SITE DIAGRAM
2
DCHD(6-82)