P4796 Farmington Rd-^ v- -—w.,.,.,,...Vwygav-�.r � ..:�+"Y.ireG„".:�a•.�,.._ r'>L:;-a'8i at.::s� •vtj�•s►.:��:x_ z.._ .. -....: .- _ -
DAVIE COUNTY HEALTH DEPARTMENT
r
.:.IMPROVEMENTS. PERMIT AND CERTIFICATEOF COMPLETION
*NOTE: Issue 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 Q � Zia ��a i \�1 S cows Date �' �� - 67 f?q % �6
pp ,
` '
Location :.4D• J � f�s� �r �•:s. _ �s��•�su�;:s�=�..�. .� °�. �.�.� � � �—
Subdivision s o Name. Lot No. Sec. or Block No.
Lot ;Size' House Mobile Homit e — - Business -- Speculation
No. Bedrooms 3 �' No. Baths No.., in>•Family
Garbage Disposal YES p NO X'w. �.
p Specifications'for System:
Auto Dish Washer YES "NO
Auto; Wash Machine YES NOr
.� ..
•-
Type Water Supply ---
*This permit Void if sewage. system described below is not installed within �36 months from date of issue.
a
Improvements permit by
*Contact a representative Of the Davie County Health Department for final inspection of this system between 8-.30-
A. M.
:30-
A.M. or. 1:00-1:30 P.M. on day, of completion. Telephone Number: 704-634-5985.
Final; Installation Diagram: ystem Installed by•'��
jj Certificate of Completion-. li"/T 7,
Date
*The §igning of this certificate shall indicate that the system described above has been installed in' compliance wi h
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.
�P-APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT ol-09Davie County Health Department
Q„ 1" Environmental Health Section c �V
l/° ��✓ ✓I' P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 9t 76 a/06'
1. Permit Requested By aat�- �4� Business Phone
2. Address LL p 61 24�W(, 2-�sA4�2?,G , a U R' �!
3. Property Owner if Different than Above
Address
4. Permit To: a) Install f 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 V Business
IndustryOther
b) Number of people 13
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:
commodes ✓ urinals
lavatory —
dishwasher
showers
sinks ✓
8. a) Type water supply: Public12Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions
b) Land area designated to building site
garbage disposal
washing machine 1l
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.
�i % �
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
1- 4�-a verC
4,
DCHD (6-82)
F
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name—
Address
ame
Address
FACTORS
ARE AREA
Date `o: v V
Lot Size
AREA 3 AREA d
1) Topography/ Landscape Position
S
S
PS
U
S
PS
U
?) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
PS
U
S
PS
U
S
PS
U
3) Soil Structure (12-36 in.)
Clayey Soils
U
U
S
PS
U
S
PS
U
1) Soil Depth (inches)S
PS
PS
U
PS
U
S
PS
U
i) Soil Drainage: Internal
S
S
U
U
S
PS
U
External
PS
U
S
PS
U
S
PS
U
i) Restrictive Horizons
Available Space
S
PS
S
PS
U
S
PS
U
1) Other (Specify)
S
PS
U
S
PS
S
PS
U
S
PS
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS rovisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD (5-82)