158 Pearson DriveDAVI'E COUNTY HEALTH DEPARTMENT
1MPR0VEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'. *Note: Issued 'in Compliance, with,G.8. of North Carolina Chapter 130—Article 13c.
Permit
Number
_ Name `i rd'::�'
— Date.
.
Location
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 r1
Specifications for System: n
Auto -Dish. Washer YES Efl NO E]
Auto Wash Machine ; YESK® NO '❑f's'
Type Water Su I -..,
yP Pp Y
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
F}
fry
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 bye
. L
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.
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 2'4/2
1. Permit Requested 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 -Division Sec. Lot o.
5. System used to serve what type facility: House Mobile Home!
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__mWCloset_
b) If Business, Industry or Other, State: Number of persons served
7
What type business, etc.
Estimate amount of waste daily (24 hours)
Number and type of water -using fixtures:
commodesy urinals
lavatory showers
dishwasher sinks
8. a) Type water supply: Public Private Community/
b) Has the water supply syst/emm bbpen a roved? Yes No_L
9. a) Property Dimensions ILLI1?p �'-y�
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? 2D4
What type?
This is to certify that the information is correct to the best of my knowledge.
Date Ow Signal e
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: /�vV
'0;X
kle�L�'
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
r
Name Date
Address Lot Size Z/41-1
�errnac ARFA 1 ARFA 2 AREA 3 AREA 4
Topography/ Landscape Position
PS
S
(::K)
S
PS
S
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Clay)
PS
S
Z2�
S
S
Loamy, Clayey, (note 2:1
US
US
1) Soil Structure (12-36 in.)
S
S
S
PS
S
PS
Clayey Soils
U
U
U
U
)Soil Depth (inches)
S
S
PS
S
PS
S
PS
U
U
U
U
Soil Drainage: Internal
SS
S
PS
S
PS
U
U
U
U
External
,
pg
S
S
PS
S
PS
U
U
U
U
i) Restrictive Horizons
') Available Space -S
S
PS
S
PS
P5
U
U
U
U
3) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Classification! Y
f) Site
�> ,
r
U—UNSUITABLE
Recommendations/ Comments:
Described by _
SITE DIAGRAM
S—SUITABLEProvisionally Suitab e
Date
DCHD (6-62)
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