315 Woodward Rd DAVIE COUNTY HEALTH DEPARTMENT
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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 Date �C,�%<''/;-, ' e L"(df104
Location ', �^r.,✓r .,i ✓I� � //
Subdivision Name Lot No. Sec. or Block No.
Lot Size , = �lr�� House Mobile Home _ Business Speculation
No. Bedrooms "' No. Baths i No. in Family_
Garbage Disposal YES ❑ NO .p'- Specifications for. System:
Auto Dish Washer YES NO ❑ s� rte:'
Auto Wash Machine YES NO ❑ ,
Type Water Supply '
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
Certificate of Completion `�`�Qn4� Date (c- °2j
*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.
f.. 1
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name `-A`�(- nw" fL Date /0- lU , F3
Address co ]g;?K Lot Size �u
tUbusul NL 2-?C)
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
o
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils
U 8 t
4) Soil Depth (inches) S S S S
P PS PS
U
5) Soil Drainage: Internal S S S
External S S S S
PS PS PS PS
U U UU
6) Restrictive Horizons +WIZZ Ute.
7) Available Space S 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
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by SAS Title -'9"/7-ARJAK) Date /0-/0-
,,SITE
O/0 -,SITE DIAGRAM
4 X
DCHD(6-82)
y'7 APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
�
) Environmental Health Section
1a �(�' 'pd R 0. Box 665
v�' Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone q(72–Z 0(1
1. Permit Re ested ByCar Ncs�vel. Business Phone
2. Address �0 13 OX M O CX, v
3. Property Owner if Different than Above
Address
4. Permit To: a) Install--!L/Alter • Repairer
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.
House Dimensions 4 x f7a
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��, urinals garbage disposal
lavatory—5a. showers washing machine
dishwasher sinks
o -
8. a) Type water,supply: Public Private Community
b) Has the water supply system been approved?Yes = No-
9. a) Property Dimensions (7
b) Land area designated to building site
c) Sewage Disposal Contractor 0'a-r-nix (, 4n r)�'-
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? no
What type?
This is to certify that the information is corr ct to theest n wl dge.
I7
Date Own )gnafure
OWNER IS SOLELY RESPONSIBLE FOR COMP /ANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
C'S-'' 40 food arch`) �d 4ur r, 4-
U
DCHD(6-82)
7
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P, O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S ���5�- S S
tp
�PSJ PS PS
U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS PS
U U U
4) Soil Depth-(inches) S S S
PS PS
U U U U
5) Soil Drainage: Internal S S S
j PS PS PS
External S S S S
PS PS PS PS
U U 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
Ute^ U U U
9) Site Classification - 0
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title �/� Date Z-96��
SITE DIAGRAM
a
DCHD(6-82)