1400 Cornatzer 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
v 12
Name S :ic'i, .�1 C �� ,, f % 1 ' J r/v Date
Location
Subdivision Name
Lot No
Sec. or Block No
Lot Size i�/,F�rHouse Mobile Home Business _— Speculation
No. Bedrooms J No. Baths "? No. in Family _
Garbage Disposal YES ❑ NO ,E] Specifications for System:
Auto Dish Washer YESNO ❑ / ; ; _"��= i= -�
Auto Wash Machine YES Q.., NO ❑ �C%/
Type Water Supply r _—
*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
Irtificate of Completion 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, bufshall in NO way be taken as a guarantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665 R�r+
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Req,ui�ested By d ^n `t- / % V
2. Address 1lf -2-96C!: /�5 Ald Z422:.c
3. Property Owner if Different than Above
Address
4. Permit To: a) Install�Alter Repair
b) Privy Conventional Other Type
Ground Absorption
C
Home Phone 519 f 7 (. yc/
Business Phone 9'i e 9 G 5L-';/
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home kL Business
IndustryOther
b) Number of people
6. ar If house or mobile home, state, size of home and number of rooms.
House Dimensions `r '�10
Bed Rooms__ Bath Rooms —a 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 d�- urinals
lavatory a,Lshowers
dishwasher sinks _
garbage disposal
washing machine
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? YesY No
9. a) Property Dimensions y._7 /r,/`e-L
b) Land area designated to building site `�- '7r—�eS
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? D
What type?
This is to certify that the information is correct to the best of my knowledge.
cr
Date Owner Signatu
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
rod -car—
DCHD (6-82)
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F
Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section,
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date //� a
Lot Size
FAnTnRR I ARFA 1 AREA 2 AREA 3 AREA 4
1) Topography/ Landscape Position
S
S
S
S
PS
PS
PS
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
`-G
PS
PS
U
PS
U
U
S) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
<f?
U
U
U
i) Soil Drainage: Internal
�S
S
S
S
P�
PS
PS
PS
External
S
S
S
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
PS
U
U
U.
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Site Classification
,
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provision
Described by Title
SITE DIAGRAM
DCHD (5.82)
Date