309 McClamrock Rd DAVIE COUNTY HEALTH DEPARTMENT i
ZVI_ f 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-.1968) Permit Number
Name ate
Location
Subdivision Name Lot No. Sec. or Block No. '
Lot Size C House A!'� Mobile Home _ Business Speculation
No. Bedrooms ��� No. Baths ! _ No. in Family _
Garbage Disposal YES ❑ NO p! Specifications for,System: f
Auto Dish Washer YES NO ❑ , ,-'
Auto Wash Machine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by — % f
*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
fir{
llvheCertificate of Completion � Date �n
-*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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS P&WNE
Davie County Health Department
Environmental Health Section
P. O. Box 665 d
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
t Home Phone
1. Permit Requested By Th X Y e R6rV ,,8QU)fA?6 Business Phone '7!P
2. Address /YIC' 01,9mPock k
3. Property Owner if Different than Above
Address
4. Permit To: a) Installer Alter Repair
b) Privy Convention al_XZOther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: HouseM bile Home Business
Industry Other
b) Number of people a
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions !y/y '1r,
Bed Rooms—Bath Rooms a. Den w/Closet
b) If Business, Industry or Other, State: Number of persons served SIA
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes vp 3 urinals garbage disposal
lavatory 4a� 3 showers washing machine
dishwasher / sinks 1
8. a) Type water supply: Public Privately Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 00A_P_ :S
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? NO
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:
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DCHD(6.82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. 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 S S S
PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soilsr`) US PS US
1 N 4V .--
4) Soil Depth (inches) S S S S
P P PS PS
U U U
5) Soil Drainage: Internal S __�y� S S
S lPS/ PS PS
U
U U
External S S S S
PS PS
U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS PS PS
U U U U
8) Other (Specify) _ < % S S
/rf
qS '"'``PPS PS PS
C� U U U U
9) Site Classification
U—UNSUIT
ABLEE PS—Provisionally Suitable
Recommendations/Comments:
�(�
Described by `,lC � Title /t/ Date ����
SITE DIAGRAM
1
DCHD(6-82)