P4102 Cornatzer RdZj J,
Subdivision Name- Lot No. � Sec. or Block No.
Lot Size House 4 Mobile Home — Business Speculation
No. Bedrooms �_�� No. Baths dam' No. in Family r
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ z—
Auto Wash Machine YES ❑ NO ❑ �� �� �
Type Water Supply
"This r)ermit Void if sewage system .described below is not installed within 36 months from date of issue.
—�del
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 b/ Y/L, � 171,
��S
Certificate of Completion2d, %;\ �� e,�✓
*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
Sew ge Treatment and Disposal Rules (10 NCAC 10A .1934-.1968)
Permit
Number
Name
n ��+%i Date
�!i E '
1 J 2
Location
Zj J,
Subdivision Name- Lot No. � Sec. or Block No.
Lot Size House 4 Mobile Home — Business Speculation
No. Bedrooms �_�� No. Baths dam' No. in Family r
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ z—
Auto Wash Machine YES ❑ NO ❑ �� �� �
Type Water Supply
"This r)ermit Void if sewage system .described below is not installed within 36 months from date of issue.
—�del
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 b/ Y/L, � 171,
��S
Certificate of Completion2d, %;\ �� e,�✓
*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
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name 1?!n j Pow Date
Address Lot Size f db X Zoo
FAr:Tr)R.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
S
Loamy, Clayey, (note 2:1 Clay)
<::TD
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
<�
PS
PS
PS
U
U
U
U
G) Soil Depth (inches)
S
S
S
S
jp
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
U
I) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
!) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE <� —P—Provisionally Suitable
Described by Title ^- �•�• Date
SITE DIAGRAM
V4
DCHD (6-82)
Ja - Z$ -aj,
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone�_a�
1. Permit Requested By Business Phone :7ZZ!_ &h
2. Address -Od
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 ty a facility: House I 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
Bed Rooms 3 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:
Aci bq5etitL
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 L," 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 Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
lv -2-F,-9�
DCHD (6-82)