331 Potts 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 �� .lL�� �AZ"-l1?L Date �2` 7 Cr?_ �`�- 1 3610
Location JSFf - d / Su,,;E� . �fr~'-� --)iV 0,7-7c
Subdivision Name Lot No. Sec. or Block No.
Lot Size 3 '�— House Mobile Home ---.!:' -Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES ❑ NO ❑ stem:Specifications for S
Auto Dish Washer YES E] NO ❑ p y 000 C�cwN n���
Auto Wash Machine YES E] NO -❑ 20o X 3 x f z�
Type Water Supply WE - , _ -�J) - iSZ"x cru Co.-/curt
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
J�
r tZ c NT
O! Wk c �-
Improvements permit by--;; A'
"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
l
a
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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PER IT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone a g — 12 q r1 1.
1. Permit Requested By Z \ t Business Phone
2. Address "a,Irl\`\ 0 Locki, ", onA n.- 11) :Vn5IT101r, – So.\gm
3. Property Owner if Different than Above
Address //
4. Permit To: a) Install�L 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 I
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions—
Bed
imensions Bed Rooms—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 urinals garbage disposal
lavatory 2L showers `k washing machine
dishwasher n sinks
8. a) Type water supply: Public Private-Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions A.)AI,r e-e_ a r• r f
b) Land area designated to building site
c) Sewage Disposal Contractor Ci d.it G a,a,10 L�
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? n
What type?
This is to certify that the information is correct to the best of my knowledge.
ate bwner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
o \ -�o Pia v arc e
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name RAY 6AMT-lc� Date
Address Z7'10 Lot Size Ac-pie-T-
/V
FACTORS AREA 1 AREA 2 AREA 3 AREA 4 .
1) Topography/Landscape Position S S S S
(TD dF19 PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) ® '(a 1. PS
U U V U
3) Soil Structure (12-36 in.) S S S S.
Clayey Soils (!M ci3 rPt9 PS
U U `tJ' U
4) Soil Depth (inches) S S ,S S
PS
U U U U
5) Soil Drainage: Internal S S S
(AP PS
U U
External S S S_ S
7�Pj5� PS
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 P —Provisional y
Recommendations/Comments:
Described by � Title Date
,SITE DIAGRAM
X X
P
DCHD(6-82)