5866 Hwy 801S -- DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE. OF COMPLETION
'MOTE: 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 %''!� ,ice ! C" 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 ❑ NO ❑ Specifications for System:
Auto Dish Washer YES -NO -E] `' -'
Auto Wash Machine YES p NO
Type Water Supply _—
*This permit Void if sewage system described-below is- of installed within 36 months from date of issue.
T
l
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 �-
+i 1 3" ra
k 2
/.75� alp
C
�V\L,,PA
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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.
SP
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 C '� -7
1. Permit Requested By UJI 1 1 A R Qry Business Phone
2. Address I (s U o S'P`6 D r-. 2 q ( e%e �L3j 112 tj. c .
3. Property Owner if Different than Above Witlfam G • Py
Address 124 1 Mocks,k s () l` I'e- N. C.
4. Permit To: a) Install Y Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division W644C Sec. Lot No.
5. System used to serve what type facility: House ✓ Mobile Home Business %
IndustryOther
b) Number of people r
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions S3 A"x �� W�a0�°"X 4� f b "&-grcx3e, .
Bed Rooms Bath Rooms Den 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 -, 3 showers 2 washing machine
dishwasher I sinks
8. a) Type water supply: Public V_ Private Community
b) Has the water supply system been approved? YesJe!'_"'No
9. a) Property Dimensions A
12rJ5 A c+'
b) Land area designated to building site _ t Ar-
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 correQt to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
C'oN7`' �f w �ll+�� ►� C SP0'y T` a(cNry ,)eajoAId raqI/ 7"c Sro
7'ur-,v IefT" om 80 / qo abouf- l� Aft/le-s' 'at Sc-catUct bi-, cls fto s
d0 f lw fro ti+ o:f W11 l<'fr /}ccess Rr,cq•
7-elere o , I qV- 91r2 1j
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �� Q.m /✓� Date Trl/L�
Address ,��[� Lot Size_,���
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S. S S
PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils 4 S PS PS PS
U U
4) Soil Depth (inches) S S S
1p PS PS
U U U
5) Soil Drainage: Internal S S S
S PS PS
U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
PS S 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 _ Title Date
SITE DIAGRAM
DCHD(6-82)