2740 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 Dis osal Rules 10 NCAC 10A .1934-.1968) Permit Number
Name r -',i^� � %'� �G' Date f/�� � L: !77
Location _ z /�L/ ��f f +�,r`.
Subdivision Name Lot No. Sect or Block No.
Lot Size �'%''C House Mobile Home L` Business Speculation
No. Bedrooms No. BathsNo. in Family • _
Garbage Disposal YES p NO p' Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Machine YES NO p c%
Type Water Supply
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
1
Improvements permit by
*Contact a representative of the Davie Ciounty Health Dep [ e t for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of co T'eleph umber: 704-634-5985.
Final Installation Diagram: ff (System Installed by .
Y
✓� a
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
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 Requ sted By Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓Alter Repair
b) Privy Conventional Other Type—
Ground
ype ��� –
Ground Absorption!
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions ,�� X 7 D
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
b) Has the water supply system een appy s No_f✓
a) Property Dimensions
' ". b) Land area designated to building site
c) Sewage Disposal ntractor
10. Do you antii " e any dditions or expansions of the facility this sewage system is intended to serve? �d
' What.t,
This-
yis to certify that the information'is correct to the best of my knowledge.
t4 ate Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82) ��
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position �5� S SFS
U --LJ U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) d5 S PS
U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils P,$ PS �� PS
Sk U
4) Soil Depth (inches) S S S
PS
U U
5) Soil Drainage: Internal S S S S
P PS � PS
U 0 U
External S S S S
�S PS PS
U
6) Restrictive Horizons
7) Available Space S S � S
0PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification P'" , , U' S� [/L S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by 1 �� Title Date A
11
SITE DIAGRAM
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DCHD(6-82)