996 Baileys Chapel RdDAVIE 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
Name:/. ;K Date3916
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
Auto Dish Washer
Auto Wash Machine
Type Water Supply
YES p NO El
YES p NO p
YES E] NO—E]
Specifications for, System:.-;
"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.
95
I'
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT /A4 -
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 �•� 1 I� }E:G�S Business Phone
2. Address `ID i�enne:l• lar.-.c� `3µ:►clw
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 v Mobile Home Business
IndustryOther
b) Number of people of -
6.
f6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms ;L Bath Rooms :L 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
lavatory showers
dishwasher sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private ✓ Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ! 2 &t ras
b) Land area designated to building site
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 correct to the best of my kno ledge.
aI- g.g�' X 3 V - Z la=' -,
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
got - ,>vj_ c-$ 4.1(A &yj W - I s -,t-Q- 4.,,
ems. V, —s -C- Q,,. s: Jt- _�u -iC:'..&.���I�.•-�-
DCHD (6-82)
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date ✓ � e
17
Lot Size fy'�
GAr'TnRC ARFA 1 ARFA 9 AREA 3 AREA A
Topography/ Landscape Position
9)
SS
S
PS
S
PS
U
- U
U
U
!j Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
—p
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S j
d@>
S
S
PS
S
PS
Clayey Soils
U
U
U
U
1) Soil Depth (inches)
S
S
PS
PS
PS
U
U
U
) Soil Drainage: Internal
PS
*>
S
PS
S
PS
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
PS
S
S
PS
S
PS
U
,U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title Date
SITE DIAGRAM
DCHD (6-82)