253 Sheffield Rd DAVIE COUNTY HEALTH DEPARTMENT
•� . IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE_7IPs.ued-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 ND 5525
Location `' � N�"I"..
l� `� t,l,) \� c� -� _ , _ ` ` , � _� � O Via, •��:� (1,
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 fl NO [�}�
_. Specifications for System:
Auto Dish Washer YES ❑ NO -
Auto Wash Machine YES ry NO fl
Type Water Supply c> ., . �y _ _ y� X + �,
*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 F.'--- =a�
*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. x
,Final Installation Diagram: System Installed by
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Certificate of Completionu —
Date
*The signing of this certificate shall indicate that the system describ abovhas been installed in compliance with
the standards set forth in the above regulation, but shall in NO way be taken a 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 Q PP
P. O. Box 665 RcC�`vE
Mocksville, N.C. 27028 G
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
c, Home Phone
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1. Permit Requested By 7 a �' C r CJ�• Business Phone
2. Address KA ,R Qok 4-50 M n c K Sv I)e /v -c a-'1 D a
3. Property Owner if Different than Above A ,
Address S°-M D`S boy2
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 Two
6. a�If house or mobile home, state size of home and number of rooms.
House Dimensions 14 X 10
Bed Rooms 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 a urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system be n approved? Yes-*"' No
9. a) Property Dimensions— &A-C f e s
b) Land area designated to building site GL C 1��-
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.
Date Owner Si 9nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
CIA/
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Pte-S 7
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name &';�s i Wr' Date
Address Lot Size a QUA
FACTORS AR A AR A R CA3,, ARE6
1) Topography/Landscape Position S S S S
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
U U U U
3) Soil Structure (12-36 in.)
Clayey Soils pS US
4) Soil Depth (inches) (�pijS
U U U
5) Soil Drainage: Internal
U U U
External SZS
P —ZP PS
U U U U
6) Restrictive Horizons
7) Available Space S S
A C-ps-\
U U
8) Other (Specify) S S S S
PS PS PS PS
U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title -���—M ���n-�- Date '
SITE DIAGRAM
1 6a 6
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a
DCHD(6.82)