P4575 Sandpit Rd s
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-.1968) f Permit Number
Name ' Date yah
Location /S V
Subdivision Name Lot No. Sec. or Block No.
Lot Size �r� House Mobile Home 2� Business__ Speculation
No. Bedrooms No. Baths �/ No. in Family. 5' _
Garbage Disposal YES ❑ NO [2-- Specifications for System:
Auto Dish Washer YES NO ❑ , ,
Auto Wash Machine YES NO E] Z,/`Y
Type Water Supply 111or
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
r
Ivements,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
(IC
,
Certificate of Completion Date
*The signing of this certificate shall indicate that the system described above 4as 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.
i
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
{ Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028 DECEIVED NOV d 5 19$6
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phoneq c/.9 - a G o 5�
1. Permit Requested By �^ t � �' (7! r '�� ► S r'' Business Phone `( $ -9`111
2. Address 19 o--1L 3 Cr 8 T— '� 1 4 f/ N C_ -e- y /V C '7a o 6
3. Property Owner if Different than Above sa (I '�c C27
Address
4. Permit To: a) 5tTVRepair
b nv Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House—�e Ho Business—
Industry—
usiness Industry Other
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /;Z X 6,S- '
Bed Rooms—Bath Rooms_Z 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 1 urinals garbage disposal
lavatory ! showers washing machine
dishwasher sinks l
8. a) Type water supply: Public rivate Community
b) Has the water supply system been approved? Yes No-
9.
o 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?
This is to certify that the information is correct to the best of my knowledge.
l/- 3 - FCP=::::: " Com . .)2
Date Owner Signature 61
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
s 3
at, h
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION Y,
Name \� Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS 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
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
CA PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space 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
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by \, �Cs�� Title -� Date
SITE DIAGRAM
DCHD(6.82)