2017 Angell Rd a
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 Date )/, r�/4:z/ 4191
Location
Subdivision Name Lot No. _ _ Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms �� No. Baths No. in Family _
Garbage Disposal YES ❑ NO p Specifications for System:
Auto Dish Washer YES NO ❑ ; �, ,
Auto Wash Machine YES NO ❑ : ._, _ y;;� ''
Type Water Supply
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
J
Improvements permit by
"Contact a representative of the Davie County Health Department for findl insbection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number 704-F34-5985.
Final Installation Diagram: System Instal ed b ! f ��
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 O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMEN-1167RMIT HAS BEEN ISSUED.
Home Phone ,
1. Permit Reque d y Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Rep�ir
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot N
5 System used to serve what type facility: House Mobile Home Business
IndustryOther
Number of people
6. a) If house or mobile home, state size of me and number of rooms.
House Dimension
Bed Rooms Bath Rooms Den w/Closet ~
b) If Business, Industry or Other, State: Number of persons served !.
What type business, etc.
� I
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system een approved? Yes - No
9. a) Property Dimensions
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?
What type?
Thi is to ce i that the information is correct the best of my kno ed
Date wner Sign ure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANC WITH ALL ST E AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
(
Z7,
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
`. SOIL/SITE EVALUATION l �j
Name j Date
Address Lot Size �G
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U
U U
4) Soil Depth (inches) S S
PS PS
U U
5) Soil Drainage: Internal S S
PS PS
U U U
External �5--� S S
(�jPS PS PS
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 U
9) Site Classification
U—UNSUITABLE S—SUITABLE �PS—Provisionally Suitable
Recommendations/Comments:
Described by l'^! �% � Title Dat
SITE DIAGRAM
DCHD(6-82)