742 Peoples Creek Rd r ;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
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name 1, • l �i�- ``'�` Date �' /// t Fj "►
Location
i %2f' .t r;✓,�� ✓ I� �.r` �iCJ/ 't (^l �/% /i� J > f- r ,'l`/, /T/l -
Subdivision Name Lot No. Sec. or Block No.
L f
Lot Size �'�`�+� House f -' Mobile Home _ Business Speculation
No. Bedrooms -- No. Baths No. in Family_
Garbage Disposal YES ❑ NO p- Specifications for System:
Auto Dish Washer YESV NO ❑
Auto Wash Machine YES NO ❑
Type Water Supply
*This permit Void if sewage system described below is not i stal ed within 36 months from date of issue.
J
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 completio�/`Telephone Number: 704-634-5985.
Final Installation Diagram: Sys Installed by, ��-�
� r
I
��
Certificate of Completion '�T ��( 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.
RECEIVED
PLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ®CT 0 8 1986
Davie County Health Department
li Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028 `
DI
/ CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requ sted By a V Business Phone
2. Address '' 0
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 Home Business
IndustryOther
b) Number of people Z
6. a) If house or mobile home, state size of homed number of rooms.
House Dimensionsi !
Bed Rooms e3 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 C2* urinals garbage disposal
lavatory showers Z washing machine 1
dishwasher f sinks
8. a) Type water supply: Public Private—X _Community
b) Has the water supply system been approved? Yes No�
9. a) Property Dimensions
b) Land area designated to building site 17
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.
94'� 0,g� Z�__��
Date COwner ignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: n
121 Lj
DCHD(6-82)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name � -- Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S 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) (PS) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils C PS PS PS
U U U U
4) Soil Depth (inches) S S S
pS PS PS PS
U U U
5) Soil Drainage: Internal S S S S
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
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—Provisionali S '
Recommendations/Comments:
Described by Title �✓ Date
SITE DIAGRAMrj
rel•tb!
DCHD(6-82)