2289 Hwy 601S 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 .19�3/4-.1968) ( i Permit Number
Name S!z� t 1 c �_ <�- Date / ' �0 ` 4
i�.n
r
Location -rl SO v i!� n L.i"7" /r C/12Df
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 L'J Specifications for System: /000
Auto Dish Washer YES � NO ❑ P y
Auto Wash Machine YES .E] NO ❑ x 3 rX
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
f
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 ?PAAIQ (9ifI IG
3
LD
Certificate of Completion Date.41
'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.
''�' ►-';� " DAVIE COUNTY HEALTH DEPARTMENT
r- 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 1 OA .1934-.1968)- Permit Number
NameC r v 1� c a«� c� j(� t f
Date �'��' 3524
Location �--, / Sa v i!� dr. �.iT / C`_c
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 [ll" stem:Specifications for S
Auto Dish Washer YES [� NO' ❑ p f `` Py Oba <:, ���k �4tL
r
Auto Wash Machine YES ❑ NO ❑ 3�/� X 3 x
Type Water SupplyC"� _— - ' gif -,I "?
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
a
5
Improvements permit by —i 4 �----''
*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 �c-
f
3
Certficate of Comp etion � 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name G �l t.c,q-fLt7 Date
Address Lot Size
FACTORS. AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape PositionS
Is 'PS S PS PS
U U 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 S
Clayey Soils S lP, PS PS
lT U U
4) Soil Depth (inches) S S
PS PS PS PS
U U U_ U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U U
External S S S S
PS PS PS PS
U 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 PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date E17/
SITE DIAGRAM
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksviile, N.C. 27028
i. ,
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone a g o a 040
1. Permit RequestBy Business Phone 634-"'3591
2. Address e — 1 0
QR
3. Property Owner if Different than Above JC�4m a above.
Address
4. Permit To:a),Install Alter Repair
V b) Privy Conventional Other Type
Ground Absorption
4c) Sub-Division Sec Lot No
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 4-
6.
6. a) If house or mobile home,state size o1 homy and number f rooms.
House Dimensions_ 2 X X0 C 5 Poomsi,
Bed Rooms—Bath Rooms—Den w/Closet_
b) 0 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 1
dishwasher sinks 1
8. a)Type water supply. Public Private Community
�p
b) Has the water supply system been proved?Yes_ L No
9. a) Property Dimensions 12a9-99/)(1Q0.08 X a Q/. 6a
b) Land area designated to building site •baa cacr s
V c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? _LY0
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:'
o � from Moc ksvif le 1-o i tlte(`se cf'on
TaKe Hi�1�wgy h � soy
of H;c Wci s 601 qA $01 (Gpecjsy Corner. �0 4bo�t - rni�e ��r et`
Soub on y6�1 To mobile kom , eqpk on left. The lot i's kcgted
Olt back ofa r k o n the r t S1, of c v% Vemp
P � y
DCHD 0-84