P3625 Davie Academy 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 c c_ SYS +-r-� Date _'�73 `Ct 3625
Locationv-
17 .v .G�� v. f !]� �;— 7" r�� . J .� , • C r r r /1 F
Subdivision Name Lot No. Sec. or Block No.
Lot Size 2'0 /4L` House
No. Bedrooms '3� No. Baths
Garbage Disposal YES ❑ NO p
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑
Type Water Supply C-40"'`''"'7
Mobile Home _ '�- Business Speculation
No. in Family f _
Specifications for System:
Soo /x3'X IZ� C
P-7
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*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by��'r
*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�t��- t�"
Certificate of Completion� �w� Date / ` Ll
*The signing of this certificate shall indicate that the system describe 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 Date — S
-o07 en
Address Lot Sizey'�
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ARFA 1 ARFA 9 AREAS AREA 4
1) Topography/ Landscape Position
ACV
V
S
PS
PS
PS
U
U
U
U
�) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
S
CE)
S
(M)PS
S
U
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
t
S
<nP
S
(M>
S
PS
U
U
U
U
G) Soil Depth (inches)
S
S
S
S
®
PS
U
U
U
U
i) Soil Drainage: Internal
&-->®
PS
C®
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space �±
S
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
�S
-S
P/r
U—UNSUITABLE
Recommendations/Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE—Provisionally Suitable
Titler V� �" Datel M
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
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.
,1,, Home Phone Q% LA -aeRQ
1. Permit Reguested By , A� ► I,-�-�- S M c Tr , Business Phone
2. Address 's H P-) 4S G
3. Property Owner if Different than Above t ' Y 1 Il a 1 L,2 t_t 1uv J► ► ► ►'I r 1
Address a(Yil
4. Permit To: a) Install Z 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 Home Business
IndustryOther
b) Number of peop
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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 hou
7. Number and type of water -using fixtures:
commodes 0L urinals garbage disposal
lavatory showers washing machine 1
dishwasher sinks
8. a) Type water supply: Public Privateer Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions C C► Ch _�
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.
Irl AA/1-9-2 o2�, C 75 q'
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL,LAWS,
Allow 5 days for processing }
Directions to property:
�c»Q c p of ryi Qd
Xj�Sq Cj� "A-
o C'W3
DCHD (6-82)