533 Riverview Rd 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-.19/68) P_ermit__-Number
I Name ' ✓,i ; =/�� Date /i'/ 1 -��'<' 1'"�j196
: . ..
Location ' .r / '/ �-,"f J / f' '.<.: /��' f ✓� " .��
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home _L_ 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 NO ❑ ;,� �. tr '��� " /; c
Type Water Supply _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
. \ 1
Improvements permit
*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 byNA7 ��'
Certificate of Completion Date `
*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
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.
I T Home Phone
1. Permit Requested By '� � /� �o Business Phone l 3- S/'c>,����
2. Address . a :�-/ 70o
3. Property Owner if DifferentthanAbove .1,n L v
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional I 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 people110
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 1;2
Bed Rooms -3 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 Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions Q-C r e- t o I Lt S
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? r" o
What type?
This is to certify that the information is correct to the best of my knowledge.
9- .f"-) 9-V 3 ___/ 6f/ A r /�
Date Owner Sign ture
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
1A '�F
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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
PS (6:) PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) S –&) PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils 0-5 PS PS
U U
4) Soil Depth (inches) S S
S PS PS
U U
5) Soil Drainage: Internal S S S
PS PS
L.� U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S S
PS PS
U U
8) Other (Specify) S S S S
PS PS PS PS
U U I U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
E
DCHD(6-82)