218 Huffman Rd DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
i *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
Location
Subdivision Name Lot No. Sec. or Block No.
fi
Lot Size House Mobile Home Business Speculation
No. Bedrooms -- No. Baths No. in Family —
Garbage Disposal YES ❑ NO p Specifications for System: t r
Auto Dish Washer YES ❑ NO [}
Auto Wash Machine YES Ej NO ❑
Type Water Supply ---
*This permit Void if sewage system described below is not installed within 36 months from date of issue. Yr
i 1-. .. ti .•.1 E
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.lnstalied by ! ' - ! -
_�----_""
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.
DAVIE COUNTY HEALTH DEPARTMENT
r� Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Louis Moody Date
Address Rt. 7. Box 362-1 Lot Size 22.5 acres
MnrkGville
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position C57 . <
PS PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ® � PS 4129
U U ® U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils (:!r9> 69> PS
U U U
4) Soil Depth (inches) S S S S
t� PS '�„ PS PS i�/" PS
U U Q U
5) Soil Drainage: Internal S S S S
® PS
U ��>sy U
External S S S S
� PS
`'
6) Restrictive Horizons
7) Available Space 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—SUITABLES-Provisionally Suita
Recommendations/Comments: ?5 dam-
Described by� Title sanitarian Date
SITE DIAGRAM
2 bd
X
Zoo
Z
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DCHD(6.82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTSRERMIT
Davie County Health Department
Environmental Health Section C�7�
R 0. Box 665 <o
Mocksville, N.C. 27028 * qv�
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/ Home Phon7,o/ r 2
1. Permit Requested By ,C8 urq ll'10 ® 4.'' Business Phone
2. 'Address �!` a 4 1��t� s-�5-��r-,�����-�- Z; 7,22-
3.
,'23. Property Owner if Different than Above
Address p
4. Permit To: a) Install Alter Repair ie etc H „5 elf r1/fey CI fl R
b PrivY Conventional Other Type
round Absorption /7ont Ae�urd,,►-a►'i
c) Sub-Div(s(on Sec. Lot No. D
5. System used to serve what type facility: House L Mobile Home-, Business
Industry Other
b) Number of people '
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 2 k
Bed Rooms Z Bath Rooms y Den w/Closet
b) If Business, Industry or Other, State: Number of persons served P!' �.ac lZr S�olJ
What type business, etc. Re,A a t'L p
Estimate amount of waste daily (24 hours) :2- n �,K As 1tv >e
7. Number and type of water-using fixtures:
commodes 'Z urinals garbage disposal
lavatory showers washing machine
dishwashersinks
8. a)Type water supply: Public—Private Corrnrhunity
r
b) Has the water supply system been approved? Yes /' No
9. a) Property Dimensions 2�-� , �'e s
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?
This is to certify that the information is correct to the best of my knowledge. ,
Y`
Date V igna re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH LL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
tJ e;l c v A 140,11-4" -A o
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\ DCHD(6-82) - 1