3730 Hwy 158 r DAVIE COUNTY HEALTH .DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 13c.
99 Permit Number
Name Date
Location
s -
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 0 . NO O Specifications for System:
Auto Dish Washer. YES E NO
Auto Wash Machine YES ] NO -g
Type. Water Supply ---
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
{
Improvements permit bye°' 6
"Contact a representative of the Davie County Health Department for final inspection of this system between 8J0-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985.
Final Installation Diagram: ,L'` `�L� System I tailed by 1Jr ��- f•�
-
�
Certificate of Completion -Q-\ lMan.� 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
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION g�
Name vh U'!p b qgY- 323V Date
Address 2 �7'C .Si Lot Size a�J &'27°.1 s
o ma;/lc
/-7(— 2-
FACTORS
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position C:ff::� <=-� �� S
PS PS —PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) CiE� C-jF.:> PS PS
U U <= U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS (157 PS PS
U U U
4) Soil Depth (inches) S S S
U --(--:PS,-
U S PS
�Ll� U
5) Soil Drainage: Internal .. S S
PS PS
(� U' U
External S S
PS S PS PS
U U U U
6) Restrictive HorizonsQ
7) Available Space S S. S S
® PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U�— U� U�-- U
9) Site Classification v J• ?! U
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
eq
Described by Title Date
SITE DIAGRAM
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DCHD(6-82)
- APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 13
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.
,. 79UAi- Home Phone
1. Permit Requested By �� Business Phone
2. Address l`� _ ri _�`in �i'l�r+.�✓�c��Qs�l� . G''• 7�
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter - Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
b) Number of people 3
Ca) If house or mobile home, state size of home and number of rooms.
House Dimensions WP- 110,u P 710 f 12 i e ased
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 urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public PrivateLl_�" Community
b) Has the water supply system been approved? Yes se", No
9. a) Property Dimensions 20, 626- 0 �f
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? 1�
What type?
This is to certify that the information is correct to the best of my knowledge.
9&8
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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. DCHD(8.82)