1662 Deadmon Rd DAVIE COUNTY HEALTH DEPARTMENT
- ' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
"Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article 130.
Permit Number
Name _ Date ' `r - Z
Location _
1
Subdivision Nam Lot No. Sec. or Block No.
Lot Size House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family
Garbage Dispos I YES ❑ NO Specifications for System:
Auto Dish WashE r YES ❑ NO p.--
t
P
Auto Wash Machine YES ` `s i
Type Water Supply _—
i
*This permit Voi J if sewage system described below is not installed within 36 months from date of issue.
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
1
!! IP
7
Certificate of Completion Date
"The signing of his 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 fo any given period of time.
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 BISSUED.
Erqq Home Phone
1. Permit Re uested By Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional '� Other Type
Ground Absorption
c) Sub-DivisionSed' Lot No.
d
5. System us to serve what type facility: House ✓✓ Mobile Home Business
IndustryOther
b) Number of people Re h y /-Lu S P
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bedooms � Bath Rooms—Den w/Closet
b) If Busin ss, 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:
j comr odes urinals / garbage disposal
lavatory showers- Q i washing machine
dishwasher sinks -/
8. a) Type wter supply: Public Private Community ✓ Coca h'!
b) Has thel water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site
c) SewagE Disposal Contractor e n n !,n e
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.
oy- P1 Al
Date Owner Signature
WNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
C �c to
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
NameDate �� g ' 2—,
I
Address 2"`` 1 Lot Size Z 6 acs a.
Ste►lac ri C-
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Lanc scape Position S S S S
® PS
U U U U
2) Soil Texture (12-16 in.) Sandy, S
Loamy, Clayey, ( ote 2:1 Clay) P PS PS
U U U
3) Soil Structure (12!36 in.) S S S
Clayey Soils (:T�D PS PS
U U U
4) Soil Depth (inches) S S S S
® (1�3> ® PS
U U U U
5) Soil Drainage: Int rnal S S S S
PS
U U U U
External S S S S
� 2�� PS
U U U U
6) Restrictive Horizons F
`1
7) Available Space S S. S S
PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classificationi Zf I /!
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations i Comments: ��lf'�A �c/�3 �i,�.Q 5'4"V"6 X�.� /.ra>Z ivy' ZS/-3a
Described by Title • ` Date
SITE DIAGRAM
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Pluw � U
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DCHD(8-82) a a