766 Duke Whitaker Rdf ' a DAVIE COUNTY HEALTH DEPARTMENT
• " 1 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 �� �zr r,; .�>. Date
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c
Location
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11
Subdivision Name Lot No. Sec, or Block No.
Lot Size % House Mobile Home d -' Business Speculation
No. Bedrooms —S No. Baths No. in Family
Garbage Disposal YES p NO 2-'
Specifications for System:
Auto Dish Washer YES [ NO
Auto Wash Machine YES [ NO f.
Type Water Supply
"This permit Void if sewage sysie`m lescri
below is not installed within 36 months from date of issue.
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:
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Rgytu ..
System Installed by _
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.
r.
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:
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Rgytu ..
System Installed by _
Certificate of Completions" /,�� 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.
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f,.
Certificate of Completions" /,�� 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.
Name—
Address
•. DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size -� y
FACTORS AREA 1 AREA 2 AREA 3 ARFA 4
1) Topography/ Landscape Position
S
S
S
PS
PS
PS
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
3) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
I) Soil Depth (inches)
S
S
S
pS
PS.
PS
PS
U
U
U
) Soil Drainage: Internal
S
S
S
P
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
PS
U
U
U
1) Restrictive Horizons
j Available Spaceis
S
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
�
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (8-82)
S—SUITABLE PS—Provisionally Suitable
Title Date
r
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
r Davie County Health Department
Environmental Health Section REC�jI/EO
R 0. Box 665 . - OCT 0 9 jog-
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address inn c /!c i
Home Phone &90;� - 115�5 3
Business Phone
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 type facility: House Mobile Home Business
IndustryOther
b) Number of people Z
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions !20 Ino b% 1'e hd M e
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 hours)
7. Number and type of water -using fixtures:
commodes urinals b garbage disposal 0
lavatory �- showers washing machine d
dishwasher d sinks f
Type water supply: Public Private-- Community
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensions `3 ' 9 iA C
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? h0
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
property:
DCHD (6-82)