160 Southland Way K
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) x Permit Number
Name t� ;. :�: ,� '%;c: Date f4�. / .-�� f."TA
/ h
Location
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 ❑ NO ❑-'�
Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ �.% - ,r"
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Ll--i_�
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 byl�iL!,L CQ -•.
I �
Certificate of Completion rk , a Datet^
*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.
r►
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position � S S S
��� PS PS
U ZU U U
2) Soil Texture (12-36 in.) Sandy, �� S PS PS
Loamy, Clayey, (note 2:1 Clay)
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils czs� PS PS
U U U U
4) Soil Depth (inches) S $ S S
--4s-:i PS PS
U U U U
5) Soil Drainage: Internal � � S S
PS PS
U U U U
External ScP. PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
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
Recommendations/Comments:
Described by � L Title Date �
SITE DIAGRAM
DCHD(6.82)
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.
Home Phone
1. Permit Requested By Business Phone g99- 2.1 94a
2. Address
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 Mobile Home_._Business
IndustryOther
b) Number of people Z
6. a) If house or mobile home, state size of home and number of ro ms.
House Dimensions—),6 .X 3 d Jco �'l�rca
Bed Rooms Bath Rooms_ Den w/Closet_ n
�►
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 X urinals garbage disposal
lavatory X showers washing machine
dishwasher sinks X
8. a) Type water supply: Public—Private Community
b) Has the water supply system been a prgved? Yes-&No
9. a) Property Dimensions—
b)
imensions b) Land area designated to building site
c) Sewage Disposal Contractor 0 J{11� �►
10. Do you anticipate any additionor expansions of the facility t is sewage syste is intended to serve? �
What ty e?
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)