240 Cleary RdDAVIE 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 Date '-/�'�-.�,� b $ 35�
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size i% House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES p NO ❑ Specifications; for. System:
Auto Dish Washer YES , NO
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
*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 Qn.�o 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
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) rl Permit Number
i
-Name ,���.-- /rs «,-• 1',�>,-� .,�., ,;�'j ��- - Date 6
3551
Location
_� e i .�6 i''�} -, �•' f� ~'"ids' . ;�. S",, �' !fes""6P''(_'.'�' r) �✓ .'�,%� _ il— � •
j L�
Subdivision Name / Lot No. Sec. or Block No.
Lot Size House Mobile Home — Business -- Speculation
No. Bedrooms No. Baths _�—_ No. in Family
Garbage Disposal YES .0 NO E]'i`
Specifications for.System:. f • `.
Auto Dish Washer YESr NO
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
u
*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. I�
Final Installation Diagram: System Installed by
v �I
Certificate of Completion Date
• .a
'The signing of this certificate shall indicate that the system described above has bee,l 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
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date —
Address Lot Size
FAr.TnR.q AREA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
l) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
�) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS
PS
U
U
U
U
I) Restrictive Horizons
Available Space
S-
S
S
S
PS
PS
PS
U
U
U
t) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
I) Site Classification
45 e
I
I .
I
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by TitleDate
SITE DIAGRAM
/'• It
� v �
DCHD (6-82)
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT �l-
Davie County Health Department
-
Environmental Health Section I"
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone l`104iy9a-53&5
1. Permit Requested By )e.\SOT 1'\arle.10e _T Business Phone
2. Address IRL L . &Y, 150 - t In 'nflQASL i 1L 1e i k).(2.. x,9(7" T
3. Property Owner if Different than Above Le\SUTO - YQX-IeXee M=x-eNk-438
Address g-1 U &x \%t)- 16 MOQI U11e (L.C. 211M
4. Permit To: a) Installer Alter Repair
b) Privy Conventional 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 a
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions \"a X LAS
Bed Rooms a 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 1 showers washing machine A,
dishwasher sinks
8. a) Type water supply: Public Private_ Community
b) Has the water supply system been approved? Yes No %/ !'
9. a) Property Dimensions esju
b) Land area designated to building site
c) Sewage Disposal Contractor pollard nx\,� V00% Plumbi'XT�
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? �i n
What type?
This is to certify that the information is correct to the best of my knowledge.
14 - a rl- RLJ 'yaw" t un h Q m�yYLQ
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
ley '
wGq , ry-" L odb INba�_ 9a.
DCHD (6-82)