222 Bethesda Ln^Y: DAVIE 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 ,L) �.e4 t',�! /C Date .1 6
Location 1,1121AL i 'I/ Za/ % 611
l)�.\rC
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home — Business Speculation
No. Bedrooms 2
Garbage Disposal
Auto Dish Washer
Auto Wash Machine
Type Water Supply.
_ No. Baths d No. in Family _
YES ❑ NO Ey Specifications for System: 9 a o CV –1-a
YES p NO a
YES p'NO
A�-
*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 A)1,�a + .
Certificate of Completion �\` G^,,(ro 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name EAAg lh W )L Date 116—Z2 -Fr3
Address 57 Lot Size tt gLin.=
1(Y1 uLc
FAr.TnRc AREA 1 ARFA 9 AREA 3 AREA 4
1) Topography/ Landscape Position
S
S
PS
PS
PS
PS
U
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
�
S
PS
S
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
T
-ZE5
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
U
U
U
i) Soil Drainage: Internal
�
�
S
PS
S
PS
U
U
U
U
External
J�—
S
S
PS
S
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
S-
S
PS
S
PS
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
?S
U—UNSUITABLE
Recommendations/ Comments: S
S—SUITABLE
Described by Y A Title ��- L► c��^^� Date - Zc- -K3
SITE DIAGRAM
�N /
DCHD (6-82)
b
11
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.
1. Permit Requested 12"s !IMF -
2.2. Address 3� ,j i / i'l��L.0✓v%/lc
3. Property Owner if Different than Above 7;2!!�!
Address '
4. Permit To: a) Install_s_.�Alter Repair
b) Privy Conventional cher Type
Ground Absorption
Home Phone 4443 �'��` 2 -
Business
Business Phone
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home ✓ Business
IndustryOther
b) Number of people 7-
6.
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Z- 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 urinals garbage disposal
lavatory / showers washing machine
dishwasher "' sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions2!-u-�
b) Land area designated to building site
c) Sewage Disposal Contractor 0r W4,!=
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.
,
Date Owner Si nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
-77
Ala
CAW/
4r^—A '
DCHD (6-82)