128 Haywood Dr 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
Y ' •' '% `-S`-: � �.7
Name .-y <..ri ( ., Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House L" Mobile Home _ Business Speculation
No. Bedrooms1 No. Baths No. in Family
Garbage Disposal YES E NO E] Specifications for System: >-
Auto Dish Washer YES r NO ❑
Auto Wash Machine YES Lei NO fl J
Type Water Supply
'This permit Void if sewage system-described below is not installed within 36 months from date of issue.
��1 J
r =
Improvements permit by +
'Contact a representative of the Davie County H ent 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 ua634-5985.
Final Installation Diagram: System Inst a by
V
Certificate of Completion Date r`
*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.
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
1. Permit Requested By c7 A ML IQ, =, Business Phone -7-2.1—02/O
2. Address S 3 6 / f- n- f'M rt)7'G Q In/^ , /Y', G _Q-7/ 0
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No. 91
5. System used to,serve what type facility: Houseome Business
IndustryOther
b) Number of people
6. a) If house.or mobile home, state size of home and number.of rooms.
House Dimensions
�Be`d Rooms Bath Rooms y� 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 10
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
9. a) Property Dimensions—
b)
imensionsb) Land area designated to building site
,c) Sewage Disposal Contractor
10 Do Hou.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 FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: _.
l/fi �, S✓ dao, F7 i A/ 1-1-11wwo an
1
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION ,
Names Date
Address Lot Size ��
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S s.; S' S
APs PS PS
U `U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils =v' cPP- PS PS
U U U U
4) Soil Depth (inches) S S S S
P� PcPS PS
U U U U
5) Soil Drainage: Internal S S S S
' S� ts�' PS PS
U U U
External Ste-,. S� ..�' S S
`CS . PS PS
U U U U
6) Restrictive Horizons
7) Available Space S (S.--) S S
PS PS PS PS
�> U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification S
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
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DCHD(6-82)