206 Murphy 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 4�11e %� /� Date l= %. r ti s� 3557
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i
Location i�
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 ❑ ,�;, � .�, <, �j u
Auto Wash Machine YES ❑ NO ❑ _
Type Water Supply % __—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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
i
Certificate of Completion -- 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 betaken as a guarantee that the system will function .
satisfactorily for any given period of time.
.JL
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
S PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) /9 PS PS
U U U U
3) Soil Structure (12-36 in.) SS S
Clayey Soils PS PS
U U U U
4) Soil Depth (inches) SS S S
PS PS
U U U U
5) Soil Drainage: Internal S _ S S
PS PS
U U U
External S S S S
—._ PS PS
U U U U
6) Restrictive Horizons
7) Available Space SSS. S S
® 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— rovisionally Suitable
Recommendations/Comments:
Described by Title S''� Date
SITE DIAGRAM
X
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DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department '
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 119Z'57g3
1. Permit Requested By L Business Phone 2G-(D00
2. Address IMA r-Lls v;Ile-
3.
le3. Property Owner if Different than Above ►'Y)Ae it Pja
Address P-1" & • Box 306 /Y) orlfs4.;/Ie Al
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,HomeJe::::Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions-2 q q
Bed Rooms 3 , 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 Z urinals garbage disposal
lavatory 2- showers washing machine
dishwasher 1 sinks I
8. a) Type water supply: Public—Private Communityc gUwTr wAT-eY
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
7
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 rOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
:"Allow 5 days for processing
Directions to property:
g9e,.ir-, t --
DCHD(6-82) .