247 Turkeyfoot Rd DAVIE COUNTY HEALTH DEPARTMENT1 �
s IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewaqe Treatment and Disposal Rules (10 NCAC 10A .1934�-.11.-968) Permit Number
Date
Name _11 �', r-� ; 0 3983
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 p'
Specifications for System:
Auto Dish Washer YES NO ❑ /�,✓x1. .-r/.;:, ,./
Auto Wash Machine YES NO ❑ � -
Type Water Supply __—
U
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
i
f
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. Ieph-one� Number: 704-634-5 85.
Final Installation Diagram: System Insta led by ' =
�J
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 1'
Davie County Health Department '
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
N RUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 70 J '!!Z
01. rmituested By as , �5 /-� �l P w• e eCAf Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install ✓ Atter 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
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions t X
Bed Rooms r Bath Rooms—Z Den w/ClosetZ
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 13
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
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 to the best of m knowledge.
7-J r J 93
Date Owner Sign re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LA S
Allow 5 days for processing
Directions to property:
F,"c P er A
DCHD(6-82)
Y
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION .fes
Name Date ?
Address Lot Size
FACTORS. AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S S
63> PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) � PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils dg�) PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS PS
U U U
External S S S S
PS PS PS
U U U
4
6) Restrictive Horizons
7) Available Space S- 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 L:X5 i
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
P
DCHD(6-82)