2228 Sheffield Rd (2) y-. -.:2-'V aa:Y ..�.:.saw...✓.D,:ar3'1"ir ..a-:i-fir v'i.: ._.M„i � <. _.yi1k ` r t».1 4 n,� f i Y - '...- u. r_`. .. -F'i._. ...a. s .. ''I:`/ �L:Ms
- DAYIE-COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
wage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date Z2 N25522
~Location /%"%%U` �7 % r��/ ,�, �„� /_ %�"% r 7
Subdivision Name Lot No. Sec. or Block No.
17
Lot Size HouseMobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO
Specifications for System:
Auto Dish Washer YES [p NO ❑ �J
Auto Wash Machine YES (h NO ❑
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months,from date of issue.
V
re
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
9+g0q-
, 7
/ 4
� r
r
Certificate of Completion — ZZ Date 12 J V-2
*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.
S
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville,N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/l Home Phone
1. Permit Requested By. �G �` Business Phone 'sS�D
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install_ kter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House obile Home Business
Industry Other
b) Number of peoples5-2
6. a}If house or mobile home, state size of home and number of rooms.
House Dimensions
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-ITen approved? Yes No
9. a) Property DimensionsC
b) Land area designated to building site
c) Sewage Disposal Contractor1I
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 est of my knowledge.
Date ner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
—5;b
DCHD(6-82)
y
•T DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name /-;?/ on/DC /( Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S� S
LU S P
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) (19) PS
U ip
3) Soil Structure (12-36 in.) S
Clayey Soils (� ;S)
'U U `t1
4) Soil Depth (inches) S S SC$y
U U U U
5) Soil Drainage: Internal S
(N) (g� PS df
U U U
External S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space
PS 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 ( � Title ""� Date
SITE DIAGRAM
x�
I\( 1
f
UCHD(6-82)