166 Rock House Rd DAVIE COUNTY HEALTH DEPARTMENT , i;'I t.- j` t': .•
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETIOd' + ` '
`NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c u
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name '.. %�� .,%:: /r Date ;1f
Location
Subdivision Name Lot No. - Sec. or Block No.
Lot Size %1�'%!= 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 ❑ NO -❑
Type Water Supply
*This permit Void`if-ssewage-_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 Q> l, 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 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date
Address Lot Size��` i''
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) S PS PS
U
3) Soil Structure (12-36 in.) S S S S
Clayey SoilsP PS
�-- U U
4) Soil Depth (inches) S S S
PS P 'P PS
U
5) Soil Drainage: Internal S S S
-------PIS /PS/ PS
U U U
External S 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 Iq U U
9) Site Classification V
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by � � Title Date
Date J
SITE DIAGRAM
e
DCHD(6-82)
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APPUCATION FOR SITE EVALUATION i IMPR0VElviEN1,j PERMIT
* Davie County Health D.?partmeiit '
Environmental health Section
t
R 0. Eh lx 665
Mocksville, N.C. 27028
CONSTRUCTION SMALL NOT BEGIN UNTIL IKIPRoVEMEN78 PERMIT HAS tWFN IS"fif,
•' �Po y
'Pam_ Horne phone
1. Permit Requested By� .r�z q�Y !�� +�L__—_ (Business Phone'.1'9P
2 Address —••_—• _ --- -
& Property Owner If Dtftent thct`ri Above
_ . Address A B(v Al b&: N.G
4. Permit To: a)Instal. Atter Repair
b) Privy Conventiotial-e—__'Other Type—__
Ground At*orplion
c) Sub-Division_____ .— Sec._.__ Lot No.
8. System used to serve what type facility: House—__..Mobile Horne usineos—
Industry_--Othcr___
b) Number of people
t3. a) If horse or mobile home, state size of home and number Of rooms.
House Dimensions_ ��a
Bei! Rooms 3 Bath Rooms..2-- _Dan w/Closet-_
b) II Business, Industry or Othar, State: Number of persons served
What type business,
Estimate amount'of waste daily (2.4 hours)-----.--.--
7.
ours)._.._ —_._7. Number angtype of witer-using fixtures:
commAes— 2" —_ urinals--:_:___.—_. garbage disposal ___._
lavatory_� showers__�..—__r .washing machine—�
di9hwasber ._.L _._. sinks
a. a)Type water supply. Public_—__Privsde✓✓ —Community
b) Has the water supply system been approved? Yes��o_..—
9. a) Property Dimtnslons 3 5ZX S`30
b) Land area designated to building sits ._ �•�T CoaT�!--
c) Sewage DlspoaaI Contractor`—..___—..--_-•---•.—.-_..—.-----
10. Do you anticipate any Additions or expansions of the ftrc:ility this sewage system is Intended to serve? d
What type?
This Is to cortify that the,information is correct to the best of my knowledge.
Date Owner Si nature
OWNER IS SOLELY RESPON131BLE FOR COMPLIAN;:E.WITH ALL STATE AND LOCAL LAWS,
Allow b days for procassi
Directions to property: _. —" '�\—_------•-----�, �� -- "_.'
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