692 Pine Ridge Rd DAVIE COUNTY HEALTH DEPARTMENT
- IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'NOTE: Is.lied in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Se age 7ireatm t nd Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name C• Date r , 3903
DI-
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 ❑ - Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES [ N0 ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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 Installed by
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Certificate of Completion
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*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 Count Health Department
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Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Q Home Phone ' - 9
1. rmit Reque,5ted By 0704 N TS j�c k"c Pz P lx� Business Phone
4. Address A7� � 4o>.r A 29 mocAs v, 11C /V C
3. Property Owner if Different than Above s,J a A ro A l f R r 0
Address SAMC
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 kf Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
v'gouse Dimensions y X 49
V--B'ed 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 –3 showers washing machine J
dishwasher sinks 1
8. a) Type water supply: Public r Privateer Community
b) Has the water supply system been 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?
This is to certify that the information is correct to the best of my knowledge.
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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(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 S
u (:!!!5 U PS
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) SS PS
U
3) Soil Structure (12-36 in.) S
Clayey Soils PS
—� U
4) Soil Depth (inches) S S S
PS P S PS
U
5) Soil Drainage: Internal S
S S C3 PS
� U
External S S � S
PS PS
.R( S� PS
U U ZIT U
6) Restrictive Horizons ^/i `F4 1.2-
7) Available Space S S. S S
PS PS PS
U d 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: ---
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Described by 11/ Title Date
SITE DIAGRAM
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DCHD(6-82)