878 Chinquapin RdDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with G.S. of North Carol ina.Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name. ��rU�/`� ., J Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size % n House Z Mobile Home _ Business Speculation
No. Bedrooms --�2 No. Baths No. in Family �J _
Garbage Disposal YES.:E] NO ,;p-- Specifications for System:
Auto Dish Washer YES Q NO
Auto Wash Machine YES p NO
Type Water Supply
. v
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
n , 5/1
i,"
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 Completion_li `� � .� Date
*The signing of this certificate shall indicate that the system descried 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. E.
�d
Certificate of Completion_li `� � .� Date
*The signing of this certificate shall indicate that the system descried 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. E.
RECC- ! ®C
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
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nwronmenta ea V%' V" P. O. Box 665 P. Cta h cam &Tz'
Mocksville, N.C. 27028 t,uy, P - ggci?y Lw�f,�i
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 3P m
(4l9)
Home Phone
1. Permit Requested By Business Phone
2. Address Rt 4 6&Y 3,24 ?d1 dz&j -; W:fU hC .27055
3. Property Owner if Different than Above
Address
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: Housed Mobile Home Business—
Industry—
usiness Industry Other
b) Number of people IL
6. a) If house or mobile home, state size of home and, number of rooms.
House Dimensions 30 " 30 '�no4-7, Ao-aa .
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 .25 /� o 6,y_o
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 Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD (6-82)
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Name
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FACTORS ARFA 1 ARFA 9 ARFA R ARCA A
1) Topography/ Landscape Position
S
S
S
P&
PS
PS
U
U
U
2) Soil Texture (12-36 in.) Sandy, ,�,/ / 1
Loamy, Clayey, (note 2:1 Clay)/�j �t
S
S
PS
S
PS
U
U
U
3) Soil Structure (12-36 in.)
Clayey SoilsS
PS
S
PS
S
PS
U
U
1) Soil Depth (inches)
S
S
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
PS
PS
PS
U
U
U
External
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PSI
PS
PS
PS
U
U
U
U
O Site Classification
Ze
U—UNSUIT
Recommendations/Comments:
BLE .�— Provisionally Suitable
Described by l� _ Title
SITE DIAGRAM
LD
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DCHD (8.82)