1003 Hwy 64E 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
NameJ��;w r IeK-S Date i'ca--F 6` 3639
Location 6 rn �' 0)1 L.j PT d GTS 14 ;71/1:'J '1 ail/r t «1
Subdivision Name Lot No. Sec. or Block No.
� Al1
Lot Size House Mobile Home _ Business —_ Speculation
No. Bedrooms –� No. Baths —2 No. in Family
Garbage Disposal YES ❑ NO ❑ Spepifications Pl System:
Auto Dish Washer YES El NO E] zoo K's x
Auto Wash Machine YES ❑ NO ❑ `'` - C<r �u.
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.Saanc�Uw
.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
t
Certificate of Completio Date
*The signing of this c rtificat shall indicate that the system:described above has been installed in compliance with
the standards set fortq 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 2AL�/ S/''�I'2�S Date
Address 3 /5 �as Lot Size
AaA::7s di<<r- �v� 220'yam
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) eve? (9� PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils 42W ® PS PS
U U U U
\`4) Soil Depth (inches) S CS S S
0 PS PS
U U U U
5) Soil Drainage: Internal ® S S
`,.PS P PS PS
U U '� U U
ExternalS S
4!vo PS PS PS
6 U U U
6) Restrictive Horizons
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 `—Provisionally Suita
Recommendations/Comments:
Described byTitle S4Ne-r ' a'�l�.l Date
SITE DIAGRAM
X110
DCHD(6-82)
• '- APPLICATION FOR SITE EVALUATIONAMPROVEMENTS PERMIT
Davie Coun ealth Department
Environmenta
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone q98- 5c 4
1. Permit Requested By I S Business Phone toN-35(0l
2. Address e 4�:tlp.
3. Property Owner if Different than Above
Address
4. Permit To: a) lnstallaL.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.
House Dimensions 2 g y-
Bed Rooms_Bath Rooms_3 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-!L No
9. a) Property Dimensions k ac Ce-
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 ner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-e2)