P4350 Farmington RdJP ° DAVIE 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
Names �C^ r tib S-�",,�t1 Date �z :i:)
Location / !r`°Gt'I ��'��1-r�'/. ✓/,1fr: f (7� r ;".'s<' / .it,;_sr /Y, r I
i
Subdivision Name
Lot No. Sec. or Block No.
Lot Size �'�;/`
House
Mobile Home'' Business --
Speculation
No. Bedrooms ,� No. Baths— No. in Family �—
Garbage Disposal
Auto Dish Washer
YES ❑ NO [-
YES NO
Specifications for. System:
❑%
T
Auto Wash Machine
YES NO -E]
ILII.
Type Water Supply
127
"This permit Void if sewage syst�m described below is not installed within 36 months from date of issue
i It 11 J11
1
ao
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_lnstalied-by
,9
Certificate of Completion w" Date 26?/ --
"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.
%'� . q-3jr
• APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT 4Y �+
Davie County Health Department 2 1989
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
�P it F
ddress
3. Property Owner if Different than
Address
4. Permit To: a) Install.l2!!'_"'Alter—
b) Privy Convent._.._.
Ground Absorption
c) Sub -Division Sec. Lot N
5. System used to serve what type facility: House o. Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions ley
Bed Room&_� Bath Rooms '0-9 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
lavatory —
urinals
showers
dishwasher sinks
8. a) Type water supply: Public Private L�Community
b) Has the water supply system been Yes No.l�
9. a) Property Dimensions
garbage disposal
washing machine
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.
S2_T/ !
Date 11 t Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
Name—
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date L'�,C�S/ ��
Lot Size
AREA 1 AREA 2 AREA 3 AREA 4
3
1) Topography/ Landscape Position S S
PSj PS PS
U
�--� U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) /,�' PS PS
if U U
) Soil Structure (12-36 in.) S S S
Clayey Soils A>/1' ` PS PS
U L1J/ U U
4) Soil Depth (inches) S S
----------- PS PS
U U U
5) Soil Drainage: Internal S S S
(7('T1 PS PS
U U
External S S S S
PS PS
U
�j U U
i) Restrictive Horizons
Available SpaceS SS S S
PS PS PS PS
U U U U
1) Other (Specify) (�5 qS
S S
PS PS PS
U U U U
1) Site Classification
U—I
Recommendations/ Comments:
S—SUITABLE /PS—Provisionally Suitable
L�
Described by sl
Title -./�� � Date
SITE DIAGRAM
U—I
Recommendations/ Comments:
S—SUITABLE /PS—Provisionally Suitable
L�
Described by sl
Title -./�� � Date
SITE DIAGRAM