146 Rocky Hill Trail (3)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
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date
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 p j NO ❑ / <'
Type Water Supply
'This permit Void if sewage system described below is not installed within 36 months from date of issue.
t
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
Certificate of Completion ' �' Date
i
"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.
1� (3"19
� I - O PLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
I
:Davie County Health Department
,,._,,Environmental Health Section �O
l P. O. Box 665
1 `^� Mocksville, N.C. 27028 �G
U`
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
r, Home PhonedDO a%yam%
1. Permit Requ !ste5 By
2. Address D
3. Property Owner if Different than Above —�'1«
Address
siness Phone
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional t/ Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home i/ Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms a 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
lavatory
dishwasher
urinal
showers
sinks
8. a) Type water supply: Public °� Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 1 Adle
garbage disposal
washing machine
b) Land area designated to building site �>
c) Sewage Disposal Contractor�/Ua/i�C �lll�"y -
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 cow9t to the best oflqy kno ledge.
Date Owne Sig atur
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STA ND LOCAL LAWS
Allow 5 days for processing
Directions to property: /
A11114o 60 6 zellee0
DCHD (6-82)
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Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
��JJ
Date
Lot Size
FACMRS ARFA 1 ARFA 9 ARFA:3 ARFA A
1) Topography/ Landscape Position
S
S
S
�RSJ
PS
PS
PS
��
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
PS
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
_---
Available SpaceS
S
S
S
S
PS
PS
PS
U
U
U
U
I) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Site Classification
5
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title
Date