204 Cedar Grove Church Rd f' .. `� 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 QQEI-rt.- Date d k ; g; 3418
Location. f^ !L ."1 0 i ,rte
Subdivision Name Lt Lot No. Sec. or Block No.
Lot Size_i A<-- House Mobile Home Business __ Speculation
No. Bedrooms 3 No. Baths Z- No. in Family
Garbage Disposal YES ❑ NO g-
Specifications for System: loon �-
Auto Dish Washer YESNO
Auto Wash Machine YES [�j C]NO -F-1 .Joy h 3�� (Z� S`i
Type Water Supply b ti
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
it t(Lllo.� 12" COO (Z
1
Improvements permit by
*Contact a representative of the Davie County Hea h epartment for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. elephone Number: 704-634-5985.
Final Installation Diagram: System Installed bt �/�-• 7��- �"
i
Certificate of Completion�7�:�� .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
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION I
Name —'''�"�` � `w� Date
Address Qr' 3 Z3Z Lot Size
/Y�o��,s✓�«� NG
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
(rPS� PS PS
U
U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey SoilsP PS PS
U U U U
4) Soil Depth (inches) S S
cb PS PS
U U U
5) Soil Drainage: Internal SS S
PS PS
External S S S S
PS PS PS PS
U U U U
4
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 Cl/) � Lf�✓ Date
SITE DIAGRAM
l
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 HAS BEEN ISSUED.
Home Phone aela qu� !
1. Permit Requested By r_Business Phone 7L-0
2. Address &a, 3 a•o-J-
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Iter Repair
b) Privy Conventional her Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home VBusiness
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 3 Bath Rooms Den w/Closet3—
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 2 urinals garbage disposal
lavatoryshowers washing machine
dishwasher sinks -�
8. a) Type water supply: Public Private Community
b) Has the water supply system,been approved? Yes No c/
9. a) Property Dimensions—M
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.
/ 07
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
6Y i4V
7arp_ e• A->- 2~ flu £
164T
DCHD(6-82)