P3647 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 - fil �/ Date, "31 E� 4 i
Location
-
Subdivision Name lLot No. Sec. or Block No.
Lot SizeHouse Mobile Home --- ""'Business Speculation
�- - _
No. Bedrooms No. Baths __ No. in Family _
Garbage Disposal YES ❑ NO Q Specifications for System:
Auto Dish Washer YES ❑ NO ❑
Auto Wash Machine YES] NO ❑ /j � �IC
Type Water Supply �'! '';� . __ , >%�--fir /
*This permit Void if sewage systel 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 11A I`
rg 1 t"
Certificate of Completion G'''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.
_i
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.
1. Permit Requested By
2. Address —
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional ther Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home_L`—Business
IndustryOther
b) Number of people ,
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions A�XeeS__�
Bed Rooms Bath Rooms -7 / 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
lavatory
dishwasher
showers
sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private Community
b) Has the water supply system beep approved? Yes JNo
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?
Thisisto certify that the information is correct "bef y a4nowledDate Owner Sign
OWNER IS SOLELY RESPONSIBLE FOR COMPLINCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
Name—
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size`
FAr`TOP.q ARFA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
SS
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)
C�
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
(fD
PS
PS
PS
U
U
U
U
G) Soil Depth (inches)
S
S
S
S
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
i) Restrictive Horizons
Available Space
S
S.
PS
S
PS
S
PS
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
U
U
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments: T
Described by Title �'� Date
SITE DIAGRAM
i
DCHD (6-82)