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• 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
Name %F�� 'r �' ./i"`f!T,i,r �- Date /�i�. /��'`C"' �y
110
Location r61'r�/,-
Subdivision Name Lot No. Sec. or Block No.
Lot Size / "/C , House / Mobile Home _� Business Speculation
No. Bedrooms No. Baths ! No. in Family
i
Garbage Disposal YES ❑ NO InSpecifications for System:
Auto Dish Washer YES NO ❑ ,�` ,
Auto Wash Machine YES [�j_ O ❑
Type Water Supply
*This permit Void if sewa� a syst m described below is not installed within 36 months from date of issue.
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Improvements permit by ,tel
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'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 by
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Certificate of Completion
'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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
CEnvironmental Health Section
J P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone9�-
1. Permit Re u sted ByQlt7' Business Phone
2. Addressft - — —0• e ,)-,'7 U o
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
6. a) If house or mobile home, state size of home and number of rooms. 3'y��
House Dimensions
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 f urinals garbage disposal
lavatory 1 showers washing machine
dishwasher sinks
8. a) Type water supply: Public 1-� Private Community
b) Has the water supply system been approved? Yesk: o
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 my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directionsto property:
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DCHD(6-82)
'. DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name w Date
Address Lot Size'
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, 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
Clayey Soils & PS PS PS
U U U U
4) Soil Depth (inches) S S S
$) PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
PS PS PS PS
U U U
6) Restrictive Horizons
C�
7) Available Space S S S S
g 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 k
U—UNSUITABLE S—SUITABLE PS—Provision e
Recommendations/Comments:
Described by l Title Date 4Z�?
SITE DIAGRAM
-I
DCHD(6-82)