145 Feed Mill Rd (2) 2:30
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— +''•^ K J,r�-�r� Date ?- o - ?3
Location 201 14 iJ V1I&C k r ._ _
Subdivision Name Lot No. Sec. or Block No.
Lot Size 011 A House Mobile Home _ ✓ Business Speculation
No. Bedrooms7- No. Baths L- No. in Family Z _
Garbage Disposal YES ❑ NO D- fu. ti-
Specifications for System: /()00
Auto Dish Washer YES Q NO ❑ � �J
Auto Wash Machine YES NO F-1
Type Water Supply 4C2
I
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
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i int 9ff7 Sr�i:iCow,
OVr� LINES.
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: 704-633�4-5985. p _
Final Installation Diagram: System Installed by
N
V
G"moi/
Certificate of Completion _ Date7 2�
_
"The signing of this certificate shall indicate that the system describ d 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
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name iti•.r-y R- � s Date
Address s �'� Lot Size
A-D✓~c-c NC 2Z 6
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position �S,,, S S
(�► PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) Q PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Solis v PS PS
U lT U U
4) Soil Depth (inches) S S
6 PS PS PS
U U U
5) Soil Drainage: Internal GS S
PS' OPS PS PS
U U U U
External /009 S S
1S 0S PS PS
U 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 Title
. 7, .�q.�✓ Date
SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 9 9,? ifs y s'
1. Permit Requested By 1 n Business PhoO 2AV.r2_//
2. Address 12 y0dr 4 t fhurL ,[JC 7r2c)K
3. Property Owner if Different than Above
Address
4. Permit To: a) Install_r�Alter Repair
b) Privy Conventional eOther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home_ eff Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /y J( �
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 Z— urinals garbage disposal
lavatory 'z— showers / washing machine /
dishwasher _f sinks /
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes✓ No
9. a) Property Dimensions lOz� X ShC
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 corre to the best of my owledge.
7— /-E N3
Date Owner ignatu
OWNER IS SOLELY RESPONSIBLE FOR COM LIANCE W H ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)