P3562 Mocks Church Rd 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 .1934-.1968) Permit Number
Name'– 'i!;: Ri oei• n It r� z_ Date ' !;f `a`►� `: �a 3�j
Location �� T` '12 ?01 55 7Z), lApc:r--.�, CtlQtic,-i k 0. ;vZtj. I(nj-117- e:IIIv,-
Subdivision Name Lot No. Sec. or Block No.
Lot Size 1�. `l;(I<L House Mobile Home _ Business _— Speculation
No. Bedrooms 3 No. Baths Z No. in Family
Garbage Disposal YES p NO 2-- Specifications for System:��' Srn.vG 1600��•✓/ z'�.-k
Auto Dish Washer YES � NO p
Auto Wash Machine YES NO p � n�� �' -'�
Type Water Supply
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
�1Z jt
Improvements permit by
7-
"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.
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Final Installation Diagram: System Installed by
.G �Lam%✓ `�:�'`'� ��
Certificate of Completion Date
*The signing of this certificate shall indicate that the system described above has been installed incompliance 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name THomAs K EG - Date
Address VT- Z' -X I(3 Lot Size g`r
ArDurt cc 27oc;X-
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionS �S� S
S PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) <fg) PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils 4�> cf§5 PS
U U U
4) Soil Depth (inches) S S S
PS
U U U U
5) Soil Drainage: Internal S S S S
/fzes> PS
U U U
External - 4 S S
PS S
U 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 S S
PS PS PS PS
U U U rU'
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suiab
Recommendations/Comments:
Described by Title N `�`r�`'� Date
SITE DIAGRAM
Xt
x3
X
Frr�,r
DCHD(6-62)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By MAOAS &Z. Business Phone
2. Address eL 2 _h'o X//3 AoUAyc6--. ALC. ;?171,06
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-ZAlter Repair
b) Privy Conventional_j,��Other Type
Ground Absorption
c) Sub-Division Sec. Lot No. ('PA4r°� MAPF-BS�c.SS)
5. System used to serve what type facility: House Mobile Home_ f Business
Industry Other
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 4���X�y�
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 2 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Publics Private Community
b) Has the water supply system been approved? Yes No_L
9. a) Property Dimensions 'Z. 169 ccxe:-F
b) Land area designated to building site
c) Sewage Disposal Contractor ��11��,,,,
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? QLD
What type?
Thi is to certify that the information is corre 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:
HW Y. TO/ 504f7T/4— 11PP 3 MZZ &S' 7'a sR 162 1/-
7'61 RN R7- G//7"- &A %v M.zC
F.zYRsT- 1-10iu-r d e l7?Gf/T,
DCHD(6-82)