P4138 Boxwood Church Rd*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by 'ter
*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 T T) ��� PI C-")
-11K
3
k—j
0 3
DO
���• �JinG
Certificate of Completion %' �,: �� /WL''.Date '
p —T-.^ _ 1
signing of, this certificate_ shall indicate that the system described above has been installed in compliance with
standards set forth in the above regulation, but shall in NO way be as a guarantee that the system will function
1 ctorily for any given period of time. -
DAVIE COUNTY HEALTH 'DEPARTMENT
A. . IMPROVEMENTS
PERMIT AND ,CE TIFICATE OF COMPLETION
+
*NOTE:``Issued in Compliance
with G.S. of North Carolina Ch Ater 130 Article 13c `� y
Sewage Treatment and Disposal Rules (10 NCAC 10A..1934-.1968) PeV-nl 1`11- mber
Name �J��'<
//✓. f„� '",e�'�',;,' ��/D te��L����
Location : - i ,r __ ,, , ; �r%:, y.- /j''�'; f __ '� C� G;lc.;!t� r'f r "� 1
,,✓ ./
Subdivision Name
i
- Loi No. Sec. or Block No.
Lot Size ��
House Mobile Home = Business y Speculation
No. Bedrooms
No. Baths �-� No. in Family S _
f ,
Garbage Disposals
YES ❑ NO ❑
Specifications for System:
Auto Dish Washer
YES NO ❑
/, ��'� r ' y� r!i �'k 1/
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 'ter
*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 T T) ��� PI C-")
-11K
3
k—j
0 3
DO
���• �JinG
Certificate of Completion %' �,: �� /WL''.Date '
p —T-.^ _ 1
signing of, this certificate_ shall indicate that the system described above has been installed in compliance with
standards set forth in the above regulation, but shall in NO way be as a guarantee that the system will function
1 ctorily for any given period of time. -
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
j SOIL/SITE EVALUATION
Name—�fl� �>z �' Date
Address Lot Size —Fr"ye7
FACTORS AREA 1 AREA ? AREA 3 AREA A
i) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
A
PS
PS
PS
U
U
U
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
I) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
PS
U
U
U
External
S
S
S
/-�
PS
PS
PS
l
U
U
U
i) Restrictive Horizons
�—
j Available Space
S
S
S
PS
PS
PS
PS
U
U
U
U
{) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by � / Title
SITE DIAGRAM
DCHD (8.82)
�.
Date
0 if
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT I
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone AV
1. Permit Requested By �4 r, a MS Business Phone
2. Address A. q, 8;A 2-q9 Mack -,0" 11 e__
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair —
b) Privy Conventional—V Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home - Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions -q-0( K' E' tom.
Bed Rooms 3 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)' 19.2�-
7. Number and type of water -using fixtures: '&;k
commodes
lavatory
dishwasher
un
showers
sinks 2 -
8. a) Type water supply: Public v Private Community
b) Has the water supply system been approved? Yesse No
9. a) Property Dimensions -4'x W_Z4" 6-0+
garbage disposal
washing machine
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
What type? G tea. t� t `Z!u�^-►� �2 $4 c
N
to serve? �-
"This is to certify that the information is correct to the
best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allows days o� roce -., h 6 a
Directions to property: LWba,.t.•-
J _ *moi �_ to ! ' • `'' x7b
DCHD (6-82)
R -vi- .J � t. 4rpar' )
AZ,j 96d :r-4