370 Log Cabin Rd - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: IssuQd in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sowage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name �/ < Date ./. Eg'
Location
Subdivision Name ��sK f'-�`Lr'l � Lot No. Sec. or Block No.
Lot Size / ' House --� Mobile Home Business Speculation
No. Bedrooms No. Baths _ _ No. in Family _
Garbage Disposal YES ❑ NO -D'
Auto Dish Washer YES NO ❑ Specifications for System:
EAuto Wash Machine YES NO ❑ ,, / �]/ / ,l
Type Water Supply
*This permit Void if sewage system described b low is not installed within 36 months from date of issue.
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: Sys tern
f
Certificate of Completion Date f %_
The signing of this certificate shall indicate that the system describ d 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
/ SOIL/SITE EVALUATION /
Name 4�`e Date �C t�(�o
Address Lot Size19�.
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
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
3) Soil Structure (12-36 in.) S S S
Clayey Soils (( $' , PS PS PS
}}� U U U
4) Soil Depth (inches) S 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 S
PS PS PS PS
U U U U
6) Restrictive Horizons /
7) Available Space C� S S S
PS' PS PS PS
U U U U
8) Other (Specify) SS pS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE --PS—Provisionally Suitable
Recommendations/Comments:
Described by - Title Date
SITE DIAGRAM
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. /
Home Phoned
1. Permit Reque ted By Business Phone
2. Address lie
3. Property Owner if Different than Aove
Address M AT ILW B a V,
4. Permit To: a) Install Alter Repair
b) Privy-L—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 2
6. a) If house or mobile home! ate side o home and number of rooms.
House Dimensions-/ 7 2!
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 showers washing machine
dishwasher sinks
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 my knowledge.
Date 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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