105 Point Rd i DAVIE COUNTY HEALTH DEPARTMENT
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IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c 1
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name y> <<—� ,l� r.r: :Date �
LocationP-dl
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 p--- Specifications for System:
Auto Dish Washer YES p� NO ❑ f�,�1 =
Auto Wash Machine YES ❑ NO
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
7
p
Certificate of Completion Date-- A-)
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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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Donald L. Jackson Date ��//
Address Lot Size /7y
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
(t) PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey SoilsPS PS PS PS
U U
4) Soil Depth (inches) S S S
di) 09 PS PS
U U U U
5) Soil Drainage: Internal S S
PS PS PD
U U U
External S S
PS PS PS
U 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—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD(6-82)
• APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department RECE1viid
Environmental Health Section i9S86
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT H BEEN ISSUED.
16� 461_0D43
Home Ph ne
1. Permit Request d By n 0, Business Phone e-
2. Address J b oX 3d - 364 Adam3+ 'RS oenee/t, /�•C• zFbZ"1
3. Property Owner ifD' erentthanAbove f UAees
SaF �sir�a�+ar �iSSlanaru aQ�+S� I�sSor.ia�+etit
Address ale, !Zid 19 z z, - -Pb%A - Q r m Y.o4
4. Permit To: a) InstalUL 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
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �� ��r ��P � � �CX 7D
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 \ - K, I(_k",-\
8. a) Type water supply: Public Private ✓ Community
b) Has the water supply system been approved? Yes✓ No
9. a) Property Dimensions 11'• R z- Q 'L(-65
b) Land area designated to build'
c) Sewage Disposal Contractor b W o n �-
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? b
What type?
This is to certify that the information is correct to the best of my knowledge.
�h 9 , Iqg& &�-� &.�,
Date ner 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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