P5260 Holiday AcresDAVIE COUNTY HEALTH DEPARTMENT
�IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*t46TE: Issued in 6on1pliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules _(10 NGAC 10A .1934-.1968) Permit Number
Name -4' Date ��15'� %
L 7
Location 1'-��.�."�✓ = �f� . ,`, -moi r' Y r'. i, �, vim.
Subdivision Name
Lot No
Sec. or Block No
Lot Size zf;' House Mobile Home �''� Business Speculation
No. Bedrooms — No. Baths —— No. in Family
Garbage Disposal YES p NO g- Specifications for. S ste :
Auto Dish Washer YES E NO p `'�,.
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 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
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.
"6
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT L vs fo
Davie County Health Department
_ Environmental Health SectioniC
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED/.
D r Home Phone 19)
- • - • /_.I�� �./,1.. rye •
ne
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.,
5. System used to serve what type facility: House Mobile Homed Business
Industry Other
b) Number of people
6. ar If house or mobile home,state size of home and number of rooms.
House Dimensions -/ Y X E I
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
lavatory
dishwasher
urinals
showers
sinks
8. a) Type. water supply: Public Private Community
b) Has the water supply system been approved? Yes 1 No
9. a) Property Dimensions
b) Land area designated to building site 3v�
garbage disposal
washing machine
c) Sewage Disposal Contractor
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 c rrect to the best of my knowledge.
%Z — d' C '
d'
Date Owner Signidure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
Name_
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
/ SOIL/SITE EVALUATION 711
Date / ���
11
Lot Size 14c"
FACTORS AREA 1 AREA 2 AREA 3 APPA A
1) Topography/ Landscape Position
9)
(P�
PS
S
PS
S
PS
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PS
S
PS
U
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
p
S
PS
S
PS
U
U
1) Soil Depth (inches)
S
S
PS
S
PS
U
U
U
i) Soil Drainage: Internal
�
(P�
S�
71
jjjj
S
PS
U
S
PS
U
External
_
l
S
�
Q
S
PS
U
S
PS
U
y�
i) Restrictive Horizons
Available Space
S
PS
PS
S
PS
S
PS
U
U
U
U
I) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
Site Classification
i
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6.82)
S—SUITABLE PS—Provisionally Suitable
Title
Date