176 McDaniel Rd (2) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
X *NOTklssued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Trea ent and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date — < � N2 U
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size �`�i9C House Mobile Home _ Business Speculation P-"'
No Bedrooms No. Baths No. in Family ZZ
Garbage Disposal YES p NO [a-
Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES 0' N 0 fl
Type Water Supply k
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
1�
�Ircwf
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
a 1
Certificate of Completion f�` Date ZZ
*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.
t APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section D lts O 7
P. O. Box 665 REEF �Aw
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. C�
Home Phone
1. Permit Requested By �� K— Cr--) 1L'1.0 JAj5p(`e Business Phone
2. Address
3. Property Own r if Different than Above ��� a'
Address 12 1/
4. Permit To: a) Installe!:f-Alter Repair
b) Privy Conventional Wither Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System, used to serve what type facility: House obile Home Business
IndustryOther
b) Number of people 2�a
I
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions u0
Bed Rooms Bath Rooms ';2� 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. Numbed,and type of water-using fixtures:
commodes urinals garbage disposal
I
lavatory 2 showers washing machine
dishwasher 1 sinks
8. a) Type water supply: Public PrivateCommunity
i
b) Has the water supply system been approved? Yes Nos
9. a) Propelrty Dimensions
I
b) Land area designated to building site
c) Sewage Disposal Contractor K tc-k a . C—
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 informatio is correct the o m ow(edge.
�s 6
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: ,L 6'y` COP—/(/77-;;7,E9- . % 6-r'
C- Al'q P
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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 ��n'I GL�Q �� Date
Address Lot Size-
FACTORS
ize FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position -�
S PS PS PS
U U U U
2) Soil Texturey(12-36 in.) Sandy, -_A --5
Loamy, Clayey, (note 2:1 Clay) PSS
U
3) Soil Structure (12-36 in.) S
Clayey Soils
j U U U
4) Soil Depth (inches) S S
(01 � PS
U
5) Soil Drainage: Internal ,S� S
A (V) (��s
U
U U U
External _
PS
U U
6) Restrictive Horizons
7) Available Space (� d
4 S PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U UU
9) Site Classification -S 114- "
`C-
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by �`-°` �/ Title Date
SITE DIAGRAM
XZ
DCHD(6.82) -