322 Vogler Rd DAVIE COUNTY HEALTH DEPARTMENT
LA1p � 1I4PROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
TE: Issued in Compliance with-G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 1`0A 1934-.1968) Permit `Number
Name , �+ G ::/i —. , ,,,/ .�- yDate
Location
v
7' , r
Subdivision Name Lot No. Sec. or Block No.
Lot Size ' L House Mobile Home _ Business Speculation
No. Bedrooms No. Baths _ No. in Family
Garbage Disposal YES p NO p' Specifications for System:
Auto Dish Washer YES NO 1
Auto Wash Machine YES p NO
Type Water Supply
'This permit Void if sewage system described below is not install d within 36 months from date of issue.
Improvements permit b
'Contact a representative of the Davie County Health Department�fr final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone'Numb r: 704-634-5985.
Final Installation Diagram: yst m I tal,d
U
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 12��
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
ii�� Home Phone 76g- 7 6 a./
--U
1. Permit Requested By___ e L Uo A le r Business// Phone _ -7?3 -3 ;;Z 5-6
2. Address a $O- D,L W- S `7'I • G a,7/0T
3. Property Owner if Different than Above Na u f o r Vo a le-
Address
eAddress 3,� �o X
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 ome Business
IndustryOther
b) Number of people C
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions to C O a r* f
Bed Rooms—Bath Rooms 37- 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 710yue_� garbage disposal
lavatory �" showers washing machine, URDU
dishwasher 's sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No-
9.
o 9. a) Property Dimensions 12- 0_C-re , /o o x Zo
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? ND
What type?
This is to certify that the information is correct to the best of my knowledge.
I a- 5-- $s " U
Date O ner S nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Dateel V
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
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 c PS PS
U U U
4) Soil Depth (inches) S S
PS PS
U U
5) Soil Drainage: Internal S S
PS PS
U U
External S S S
� F s-S-D-- PS PS
U U U
6) Restrictive Horizons
7) Available SpaceS S S
PS S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification �e-.c I P� �'
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable _
Recommendations/Comments:
Described by Tit, Date
SITE DIAGRAM 1 `2
DCHD(6-82)