4271 Hwy 601N .' DAVIE COUNTY HEALTH DEPARTMENT
K
. IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewjage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name '`"%rr r /` �r Date %" %�' <',;'; ri
Location /%l� /' �r'�%
Y
14� 22
Subdivision Name Lot No. Sec. or Block No.
__Z
Lot Size House Mobile Home % Business Speculation
No. Bedrooms _ No. Baths No. in Family
Garbage Disposal YES p NO p' Specifications for System: r;'' ✓�
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ,0
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 Co my Healt Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of c mpletion. 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.
A?
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
�
Davie County Health Department
Environmental Health Section
P. O. Box 665 '
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 'PS'(0150 Lb&7"
1. Permit Requested By '4-c�+ 74n &'' Business Phone
2. Address t dedt
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.
5. System used to serve what type facility: House Mobile Homed Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 2F X 56
Bed Rooms_Bath Rooms /12 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 '2 washing machine
.dishwasher sinks
8.,a)Type water supply: Public Private Community P/
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions Grcrc�-
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 m knowledge.
i
-i-PC l ,
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
60/ ITA,, �. oZ1a (J?ow - -7,ar -
1
DCHD(6-82)
Ae
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name ��1?�� � Date
Address Lot Size %���
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
Loamy, Clayey, (note 2:1 Clay) SPS PS
)
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils ' PS PS
U U U
4) Soil Depth (inches) S S S
p
PS PS
U U
5) Soil Drainage: Internal S S
PS PS
U U
External S S S
PS
U
�-d-� U U
6) Restrictive Horizons
7) Available Space 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
9).Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisioniall
Recommendations/Comments:
Described by Ar Title Date
SITE DIAGRAM
fi
DCHD(6-82)