204 Bracken 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
Name Date '
v
3622
Location a -.1r�i't�- �%' J ' ' /.�<> f- ._. is �? 4/
— _ _ ,
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 ❑ Specifications for System:
Auto Dish Washer YES NO ❑ / ._; - 4t,
Auto Wash Machine YES NO ❑ C
Type Water Supply i %r-%`�� -- / ; �,} ���-/•r , .
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
i
i
Improvements permit by - fR
*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 describe 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.
r
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name L` U.S Date ( !
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) S PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S S
S' PS PS PS
U U U
External S S S S
PS PS PS
U
U U U
6) Restrictive Horizons
7) Available Space S S. S S
PS PS PS
U U U
8) Other (Specify) S S S
PS PS PS
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PSS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
P
DCHD(6-82)
. < : APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT ETAS BEEN SUED.
Home Phone
1. Permit Requested By �� Business Phone 13 y -may/
2. Address '�
3. Property Owner if Different than Above 16'11 911c'4e
Address /-2y
4. Permit 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
IndustryOther
b) Number of people a
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions X d
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type busi0ess, etc.
Estimate amouAt of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals Q garbage disposal
lavatory showers washing machine
dishwasher ® sinks
8. a) Type water supply: Public PrivateCommunity
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 se*age system is intended to serve? 00
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:
to cc,_4-_ej o� `}�� Q ( w � . R is'i3 �s �Qo4cL
lS /oacc if ons
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I�' /y►%le le)c4-/e C( o �-j
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DCHD(6.82)