240 Merrells Lake Rd _. .. .... ._:wi�'- T,. .. r.. ..}:.i•;;hr.pe _a. r :�..aa.:,r•r;ay.,.r.✓`s�;.L,.r,�.:�++;✓,+01-'�'^•:�^-'.-�:•r.:-^vi;:.�-3'�?''..;,r�;,ti:-:S,y''"'^'.:..,,.,q,r/"`.'-.
:.: DAVIE COUNTY HEALTH DEPARTMENT - a
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 1 c-,�z ,�r ��'� �� .=sfi.rr,'= �' Date �:t:� ��'� c :3
--�
Location /fi, /' F''� -, 1 -•i �r`�
F a
Subdivision Name Lot No. Sec. or Block No.
Lot Size 5T '/' House Mobile Home _�� Business Speculation
G �
No. Bedrooms No. Baths — �'"� No. in Family —
Garbage Disposal YES ❑ NO }/ Specifications for System:
Auto Dish Washer YES NO ❑ , / l �s� ,
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.
115 �.•����~�•�� ,
1
ry
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 Numb r: 704-634-5985.
9
Final Installation Diagram: Syste, ns II d by
d
S I �
a
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
f� Home Phone -2
1. Permit Reques ed By '✓ � Business Phone
2. Address
3. Property Owner if Different than Above
Address 11
4. Permit To: a) Install Alter Repair
—
b) Privy ConventionalL Other Type
Ground Absorption
c)Sub-Division Sec. Lot No.-
5. System used to serve what type facility: House Mobile Home_.tffBusiness
Industry Other
b) Number of people
6. a) If house or mobile home,
Jstate
/size of home and number of rooms.
House Dimensions--1 —
Bed Rooms _Bath Rooms I 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 ,7 urinals 7 garbage disposal
lavatory showers / washing machine
dishwasher sinks
8. a) Type water supply: Public Private Co unity
b) Has the water supply system been approved? Yes ,/No
9. a) Property Dimensions
b) Land area designated to building site
C) Sewage Disposal Contractor JO)l c oe
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? Ab
What type?
This is to certify that the information is correct to the best of my knowledge.
22112A
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for gLocessing
Directions to property:
12
1
'DCHD(6-82)
. w
ti
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �e Date
Address Lot Size ��
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U
5) Soil Drainage: Internal S S S S
S PS PS PS
U U U
External S S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space d5 S S S
PS PS PS PS
U U U U
8) Other (Specify) (–PS PS PS PS
U U U U
9) Site Classification
U—UN�jT�BLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by G Title –'/ Date /
SITE DIAGRAM
VCHD(6.82)
490
• 10 -
00,-. Sworn to —and-subscribed before ,r DFFICIAL SEAL
------me—this- 13th day—of_March,_1986. -- £ — ��y Public-Davie-Co.-N.G
SYLVIA E. LAGLE
�I-Commission.ExPires — —