3371 Hwy 601S C�
�� ► 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-.19/68) , Permit Number
Name / �/'r:�l '�,^ ✓rte DateL�� tip.
t
Location _i —
--------------
Subdivision Name Lot No. Sec. or Block No.
Lot Size /%'='iti'l' House Mobile Home Business Speculation
No. Bedrooms _ No. Baths No. in Family_Z _
Garbage Disposal YES NO ❑ Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO -p
Type Water Supply __ r c'l %,���}'/ ✓�
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
fir f
r-
Improy iAents permit by ✓%y' �
"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
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date
4-)
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position /�j S S
PS � PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U . U U U
3) Soil Structure (12-36 in.) S S S
Clayey SoilsS C PS PS
U U U
4) Soil Depth (inches) SS S
S —(t:D PS PS
U U U
5) Soil Drainage: Internal S S S
PS C&D PS PS
U U U U
External S S
PS S� PS PS
U U U
6) Restrictive Horizons
7) Available Space S S
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
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by 2xLTitle Date
SITE DIAGRAM
DCHD(6-82)
RECEIVED APK- 25 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 a
1. Permit Requested By �� 17bI .��/�` Business Phone�D�— ?6
2. Address �7� �c�CkSr/�1�2 /V.0
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No. At19
5. System used to serve what type facility: House—Mobile Home Business d.t�itq j' A- 7rep YDS
Industry Other
b) Number of people 19-1.0
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �d x f115
Bed Rooms 3 Bath Rooms 3 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 3 urinals garbage disposal
lavatory 03 showers 3 washing machine
dishwasher sinks
8. a) Type water supply: Public 1"' Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions /a 4 02t14 40 14L,
b) Land area designated to building site ti. 5 Q c AA,
c) Sewage Disposal Contractor &ZTZ4 ARtMICAlne7l,
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? __�e P S-
What ty a? Q�,� i/
D s
This is to certify that the information is correct to the bes of my knowledge.
ate Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
COrncv ,�
�'RoP�� tains
/3oX wood cA. rd. 6 01 -
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W0UAL Uitc a.
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\ DCHD(6-82)