P5230 Wyo Rd 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
Date ,' "
7a�s r �' a r, r' x ��a 0
Name +
Locate
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 E Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO -E] f �� ; , s. ,.
Type Water Supply ''`-r f�a --- ,.. ,k rte% ' ';✓ ""
*This permit Void if sewage system described below is not installed within�36 onths from date of issue.
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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 by
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 3i
Environmental Health Section
P. O. Box 665 r1
Mocksville, N.C. 27028
(
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTSPERMITHAS BEEN ISSUED.
I Home Phone 61 9 7 -p 3`)0
:� c , 'c"gra Business 'lbh-_5353
1. Permit Requested By �c��r 1'.) . S��� e�
2. Address Kj:"A &'X`:Zol dvohc_e N G,
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3. Property Owner if Different than Above 114 b{�c c�2
Address
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
Industry Other
b) Number of people S
6. a)If house or mobile home, state size of home.:and number of rooms.
House Dimensions /y I In
Bed Rooms 3 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 a- urinals garbage disposal
lavatory a- showers washing machine I
dishwasher 1 _ sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 10 QC r--,s
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? T" -, „} n W t- k C(4 e t-
This is to certify that the information is correct to the best of my knowledge.
2ADate Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-62)
• DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
t
Name `�,� L Date
Address Lot Size fflul
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
4?5 U U PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) S PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S S
PS 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
6) Restrictive Horizons -e3N b,
7) Available SpaceS S S
S PS PS PS
UU U U U
8) Other (Specify) !yST PS pS PS PS
I(� U U U U
9) Site Classification S,
U—UNSUITABLE S—SUITABLE S—Provisionally
�Suitable
Recommendations/Comments: — 7e `4ly" e
Described byj� Title Date
SITE DIAGRAM
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� Ss
UCMD(6-82)