2545 Cornatzer Road Lot 1Certificate of Completion' Date ^ zYr��'I
.'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. `J
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot
FACTnRS ARFA 1 ARFA 9 ARFA 3 ARFA A
1) Topography/ Landscape Position
w
9)
r
S
S
S
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot
FACTnRS ARFA 1 ARFA 9 ARFA 3 ARFA A
1) Topography/ Landscape Position
w
9)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
') Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
U
t) Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
�) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
Site Classification
i
I
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title Date
SITE DIAGRAM
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
1. Permit Requ ed B - E//>� Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Installer Alter Repair
b) Privy Conventionaler Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: HouseI obile ome Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 hou
7. Number and type of water -using fixtures:
commodes
lavatory —
dishwasher
urinals
showers
sinks
8. a) Type water supply: Public --J �Private Community
b) Has the water supply system been approved? Yes �L—L'No
9. a) Property Dimensions 0
b) Land area designated to building site
c) Sewage Disposal Contractor
garbage disposal
washing machine
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.
'/��Z� Z
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-62)
0
<;X_�Svc �ep"'V
(_'�/
Sc�D/
00
DAVIE COUNTY HEALTH DEPARTMENT _
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION J
*NOTE., Issued in Compliance with G.S. of North Carolina Chaptgr 130 Article 13c /
Sewage Treatment and Disposal Rules 110 NCAC 10A .1934-.1968) Permit Number
/ ` Jrf7'i'�r� ' ;i l'Ij ' ;/ '.:'yX &K Date r',�",��� N O 5 4. �'
Name � , , �i.� � � � ,��,..
Location
Subdivision Name _---/f
6'�1��•�%Lot No. Sec. or Block No.
Lot Size . taf 'Y- MO
House rte/ Mobile Home
_ Business Speculation
No. Bedrooms
No. Baths CZ No. in Family
Garbage Disposal
YES
❑ NO 2-"
Specifications for System:
Auto Dish Washer
Auto Wash Machine
YES
YES
NO ❑
IVO
�
EJ
Type Water Supply
�I _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
f�F
cla
J -N y ,7`"
ya /la 11'e"��-
Improvements permit by :mfr;
*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:
`p"
led by
r"
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 be taken as a guarantee that the system will function
satisfactorily for any given period of time.
C.0
DAVIE COUNTY HEALTH DEPARTMENT
.I��',,, -.� ' IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapt6r 130 Article 13c
Sewage- Treatment and Disposal Rules 0 NCAC 10A .1934-.1968) Permit Number
a"te
Name D N2
V
Location
Subdivision Name 2L, Lot No. Sec. or Block No.
Lot Size House Mobile.Home -- Business --- Speculation
No Bedrooms No. Baths No. in Family
Garbage Disposal YES E) NO Specifications for System:
Auto Dish Washer YES NO
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.
Improvements permit by
*Contact a representative of the Davie County Health Departmentfor final inspecti6n. of thii system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-6985.":,.2 ..
4
Final Installation Diagram:
S7ystns Iled by
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 be taken as a guarantee that the system will function
satisfactorily for any given period of time.