P5044 Nicole Ln DAVIE-COUNTY HEALTH DEPARTMENT
'I:1
IMPROVEMENTS PERMIT AND CERTIFICATE .OF COMPLETION o�
*NOTE: .Issued in,Compliance with.G.S..of 'NorthIParolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules;'(10 NCAC -10A .1934-.1968)- Permit Number
Name �/� i Date4.
4
�. Loicatio
Subdivision Name 1 Lot No. Sec. or Block No.
Lot Size
� House Mobile Home* Business__ ' Speculation
No. Bedrooms No. Baths
� _ No. in Family
_
Garbage Disposal YES No Specifications for System:
Auto Dish Washer � , ; YES NG
Auto Wash Machine YES- -`NO �:` U .
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by — �
*Contact a representative ofthe Davie County';: ealth 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 ��Gl� 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 regulationi;but shall-in NO way:be taken as a guarantee that the system will function
satisfactorily for any given;period of time. ;i;�
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
1 I V Environmental Health Section
�f l P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
6
/ Home Phone
1. Permit Requested By y
y8 ��n cs c cr G N Business Phone F 9f_ VE.2
_—
2. Address n t A /.ecu �Q/L A /YJac vi/,F 702
3. Property Owner if Different than Above �✓� s r'1
Address W,5�01 - 17e•cllz �✓-5.
4. Permit To: a) Install Alter Repair—
b)
epair b) Privy Conventional Other Type—
Ground
ype Ground Absorption
c) Sub-Division I Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 12 -
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions / FOO 5ft,
Bed Rooms—Bath Rooms___2.__Den w/Closet K
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 S
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? No
9. a) Property Dimensions -
b) Land area designated to building site No.
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage sysiem Is intended to serve?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date V Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: �
efl
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
,�, _ ) SOIL/SITE EVALUATION /
Name �'��� ��,��v Date—
Address
ate Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) i(P PS PS PS
`�C(( U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
Qp� PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U
External S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space � S S S
S PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U . U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally-Suitable
Recommendations/Comm
Described by / Title Date
SITE DIAGRAM
1
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DCHD(6-82)
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r- L SCALE i
1 f r L 642 q RoA.:I'.Pod'
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