211 Clark RdA;
DAVIE COUNTY, HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
='R Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
�/ hA
Name_?,%;< •.���1 Date. 4}
Location'
—T
Subdivision Name Lot No. Sec. or Block No.
Lot Sized House Mobile Home_ Business Speculation
No. Bedrooms No. Baths —,�— No. in Family
Garbage Disposal YES ❑ NO p'
Specifications for System: �^
Auto Dish Washer YES NO ❑ V L /GG'
Auto Wash Machine YES NO ❑/i
Type Water SuPPIY 4:� l ---
*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 byt��f�� , {
Certificate of Completion � Da�2.r- 179
*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 as a guarantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT VZO 0V 0 !� 1986
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone�'���
1. Permit Requested By Gnat- 'Nal? C "r n Business Phone d -595/ f'1411a/Qadle,
2. Address • PD Rey
3. Property Owner if Different than Above
Address /'b /3`y S1l`L c4e(_Pa rn�
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 Homed Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /ail- x 502 -
Bed Rooms— 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 Dimensions
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 knowledge.
Date I –OwrQr Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
5
dA P n U. G'N h Gc clC / G'td �d . - Cl,112/L .4d. YO 4112 4py
40 n �-�cn. ,e� C rte( -4 Uc h q-�zu 611-- V.,alL/17 7 0-311 1 D
DCHD (6-82)
-,4
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 ARFA d
1) Topography/ Landscape Position
S
S
S
PS
PS
PS
wo
U
U
U
') Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
(2k5
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
aD
PS
PS
PS
U
U
U
U
1) Soil Depth (inches)
S
S
S
S
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
U
U
U
U
1) Restrictive Horizons
Available Space
S.
S
S
PS
PS
PS
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by _
SITE DIAGRAM
DCHD (6.82)
Title z��-w Date
11