245 Swicegood St 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) Permit Number
NameDate r"' r ZIP: r J
Location , !,�'i' — �+�'�i` ��1 ✓ �- .fr% _ _/ �f. ft /�.
Subdivision Name Lot No. Sec. or Block No.
Lot Sizer '
_�_�� House �''� Mobile Home _ Business Speculation
No. Bedrooms No. Baths _ _ No. in Family
Garbage Disposal YES ❑ NO p'
Specifications for System:
Auto Dish Washer YES [ NO E] '
Auto Wash Machine YES Ej] NO ❑
Type Water Supply
'This permit Void if sewage system describe belo is not installed within 36 months from date of issue.
f J'
Impove ents permit by
*Contact a representative of the Davie County Health Qepart ent for fin I inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. felep one umbel: 704-634-5985.
Ss em In talled .
b
Final Installation Diagram: � � yy
Certificate of Completion Date' -
*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ���.
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C.27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
R
i Home Phone -2 9 �J -2-
1. Permit Requested By R e /e Business Phone
2. Address d -772G?d1 e e 20 W,(° 7 l)/
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ZAlter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House-v"Mobile Home—Business
IndustryOther
b) Number of people Z
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 5-1a 2 2 (o
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 Z urinals garbage disposal
lavatory showers 2 washing machine f
dishwasher sinks -�
8. a) Type water supply: Public Private Community
b) Has the water supply system been approvgd? Yes No
9. a) Property Dimensions (). / /Z A c�-e S
b) Land area designated to building site
C) Sewage Disposal Contractor cZ2 S 7.44i(6 i=
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 Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Tol
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e J 60 S T. �4 S`T y}1d % I p I'K-e t) �(> �� e T.
i DCHD(6-82) -
DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION l
Name Date �!
Address Lot Size A /I
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils S P PS PS
U U U
4) Soil Depth (inches) S S S
g (PSJ PS PS
U U
5) Soil Drainage: Internal S S S
S (PS) PS PS
U U
External S S S
p (iPSJ PS PS
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 S—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
;J
DCHD(6-82)