P4486 Becktown Rd= DAVIE , COUNTY HEALTH DEPARTMENT r �. 6-7)
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 r, ;_t . ���� ��> c� ti — Date ? %C, t� , 1
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House, Mobile Home _ Busipess _— Speculation
No. Bedrooms—_ No. Baths �•`, No. in Family _
Garbage Disposal YES p NO S Specifications for System:
Auto Dish Washer YES ❑ NO -g/
Auto Wash Machine YES �/ NO
^qr� x
Type Water Supply
*This permit Void if sewage system described,t plow 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
C
Certificate of Completion' C Dale 7 b
'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.
x
' RF�FlVED SSP
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 03 1136
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requ
2. Address A
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-AZAlter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone Wal- Sz4ly
Business Phone 6 -3 G ''F-Qc;2.Z.
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
Industry Other
b) Number of people 01
6. a) If house or mobile home,` tate size of ome and number of rooms.
House Dimensions T
Bed Rooms Bath Rooms a 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 garbage disposal
lavatory showers a washing machine
dishwasher sinks .S
8. a) Type water supply: Public Private Community 4avM� wC61eR
b) Has the water supply system been approved? Yes No_1Z
9. a) Property Dimensions /a AGie - S
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 th est of my knowledge.
vo/ /_ - 1-1 - �41 6 e %_ ��'
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
0 lZeG�t�j�a GcJ/V6�/�� ✓ rtii le
6n 121 h eperV /°aS/v/ZF w) -6A an
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1 Fejj e
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT '
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION q ,.
NameQ\ �C� ��� Date r ��
Address k �� ^ S Lot Size i2 C
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
8)
1) Topography/ Landscape Position S S S S
PS PS PS
U U U U
?) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) Qi)PS PS PS
U U U U
9) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
1) Soil Depth (inches) S S S
pS PS PS PS
U U U
i) Soil Drainage: Internal S S S
OPS
PS PS PS
U U U
External S S S
PS PS PS
U U U U
i) Restrictive Horizons
Available Space S S. S S
pS PS PS PS
U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLEPS Provisionally Suitable
Described by - �\\�`C Title - Date -
SITE DIAGRAM
OCHD (6-E2)
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLEPS Provisionally Suitable
Described by - �\\�`C Title - Date -
SITE DIAGRAM
OCHD (6-E2)