P5280 Ruffin St ' - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Se�nrage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name r. �l,�r :a„� r�1' t °x-'�I` i ; c_%`��x�j' Np Gam”°"5 t°t 0
ae 5L
Location -'��i/�''o'.*t r+ '` �,;;: �,� %✓' /% ; ;,
r.�
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 p NO ®'' Specifications for System:
Auto Dish Washer YES g NO
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.
r � `
l
__...----r-----
J,
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: Systensf tailed by
f,. t
f el
F
f
t
�17
Certificate of Completion 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 take_ n as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �` Date
Address Lot Sized'
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position Ste, S S S
& PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) elb PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS. PS
U U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U U
External S S S S
PS PS PS
U U U
6) Restrictive Horizons r---7
7) Available SpaceS S S S
S 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 we
U—UNSUITABLE
� S—SUITABLE PSS Provisionally Suitable
Recommendations/Comments:
Described by / Title . Date
SITE DIAGRAM
UCHD(6.82)
• APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 2 8tf_ 0U 5 /
1. Permit Requested By G Business Phone
(?
2. Address O
3. Property OwnR if D' erent than Above C-/a V�c� , c-fj �l-/ Win ) J YY1Ci trN
Address 1 , k 116 ✓�Is7>>�6�,%l l� /fes
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]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 Bath Rooms 2 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 cZ 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
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?
1-57
This is to certify that the information is correct he best of owl
Date Owrferygnature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)