326 Bonkin Lake Rd'-1 ., �>,:i i:.. e--•,.� , h:.";,." •+rntti:s.i ' .ori Y"•�.,. vs .::.a..,,� 1^. `- V^.: vr-. ,w �.,_.:ir.'r: ..n.� M..;, •:y::
DAVIE COUNTY HEALTH DEPARTMENT }ALJ LA
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
NOTE:Itsued 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 /rte f%4J Date
Location _
Subdivision Name Lot No. Sec. or Block No.
Lot Size%�if1� House Mobile Home _ Business Speculation
No. Bedrooms — No. Baths No. in Family__
Garbage Disposal YES ❑ NO p'
Auto Dish Washer YES �NO ❑
Auto Wash Machine YES NO '❑
Type Water Supply
Specifications for System:
I N1
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
t}
1' l
1
----�Y - 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 Completions 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.
RECEIVED SEP �a
.r
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665 VV` CC1yte Ov-(A-
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
i Home PhoneG�r
1. Permit Requested By
'. D of j Business Phd'rV �Ja?. — /� 4
2. Address - 7 10
3. Property Owner if Different than Above
Address 64 6L4 -•.4-z1 itfLJ�r e.a_r A4.1;—al(_
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 -it' -'Mobile Home Business
Industry Other—
b)
ther b) Number of people
6. a) If house or mobile home, state size of
home and number of rooms.
House Dimensions J11A 4 -
Bed Rooms Bath Rooms -3 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 3 urinals garbage disposal (�
lavatory 3 1,1� shower z'� washing machine/
dishwasher / t� sinks
8. a) Type water supply: Public Privatey'-- Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions / 7 ae'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 the best of my nowledge. ,
Date caner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FArTCIRC ARFA 1 ARFA 9 AREA 3 ARFA 4
Topography/ Landscape Position
S
S
S
PS
PS
PS
PS
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
CT
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
PS
etF
U
U
U
g Soil Depth (inches)
S
S
S
S
PS
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
i) Restrictive Horizons
ca
Available Space
S
S
S
$
PS
PS
PS
U
U
U
U
1) Other (Specify) e `�
PS
PS
PS
PS
U
U
U
U
1) Site Classification
,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by Z Title ��� v Date
SITE DIAGRAM
DCHD (8-82)