161 Shamrock Ln (4) DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
--cS�ewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size "A House Mobile Home Business _— Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO [p Specifications for System:
Auto Dish Washer YES 2" NO ❑ F_> - {- -
Auto Wash Machine YES EX NO ❑
Type Water Supply
r
"This permit Void if sewage 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 1�==� '1 - h-^-T-r -•�_,
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Certificate Completion = - Date
"The signing of this certificate shall indicate that th system described above has been installed in compliance with
the standards set forth in the above regulation, but s all 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.
Home Phone 9W'XI7D3
1. Permit Requested By Zv1f/ )g& Business Phone 35>(U
2. Address I Z' k 3 ,deo6-19- " Ab yAA) (SE
3. Property Owner if Different than Above
Address
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 401 Mobile Homed Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions �2k X &1k
Bed Rooms—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 .19,5-'X 4,SD
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 t the best of my knowledge.
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Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
R 0. Box 665
Mocksville, N.C. 27028
MSOIL/SITE EVALUATION
Name ,y �'� 1" Date I �)
Address S {> p Lot Size
FACTORS AREAS) AR 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
(::tr PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) P P PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey SoilsPS PS PS
`? U U
4) Soil Depth (inches) S S S
ch <1!9— PS PS
U U U U
5) Soil Drainage: Internal S S S
� —1J 4�0� PS PS
U U U
External S S
Au PS PS
U U U
6) Restrictive Horizons
7) Available Space
S ;S )
S S
S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U
9) Site Classification
U—UNSUITABLE S PS—Provisionally Suitable
Recommendations/Comments:
Z \
Described by Title Date _
SITE DIAGRAM
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DCHD(6-82)