207 Mason Dr .:....... �:: c-'-,. - r�� mow:..,--,,4 r : : <�.:.w.ar •=k.r,,,,,,,d r.rk`a'. s .r.' .. r . •_-a,:'.ti - ,. t -:i .... .. � _
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 .19�3�4-..1968) Permit Number
Name 3� rc� any �� `,OI (� o N Date J_ - � NDv ._ :_
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business __ Speculation _
No..Bedrooms r-� No. Baths No. in Family
Garbage Disposal YES p NO Er Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Machine YES p,/'NO ❑
Type Water Supply -- -- -
'This permit Void if sewage-,system described below is not installed within 36 months from date of issue.
El F. N
4.•
I
Improvements permit by `<'..
*Contact a representative of the Davie County Health Department for final inspection of this system between 8:30-
A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram,: �. System Installed byNL
w r - o•�
1
H
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.
rJ� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
` Davie County Health Department
Environmental Health Section 'L 4
P. 0. Box 665 � C�1V�D ApR
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 99S-4152
a
1. Permit Re uested B Business Phone 1Q 01 "51I�g
2. Address - Re-
3. Property Owner if Different than Above
Address DC( k Aoe , I!e )c�ti.2� 1��� Ju C �
4. Permit To: a) Install Alter Repair
b) Privy Conventions?�^Other Type
(G nnd_Absnrotion
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home L-- Business
Industry Other
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/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 systembeen 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 correct 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:
A2?.li4e &A,1
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION '' II
Name _,,,,5 \` 4��a� Date L
Address Lot Size—
FACTORS
FACTORS A A 1 (AREA 2 ��A3AW -�
1) Topography/Landscape Position S_
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay)
3) Soil Structure (12-36 in.) S S
Clayey Soils
U U
4) Soil Depth (inches)
U U U U
5) Soil Drainage: Internal
P
U U
External S S
U US
6) Restrictive Horizons
7) Available Space S �
S
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—Provisionally Suitable
Recommendations/Comments: �- �,,I Q°'
Described by ` / Title C!1% Date
SITE DIAGRAM
by
b�
J�
UCHD(6-82)