215 Feed Mill Rd (3)ID
DAVIE COUNTY HEALTH DEPARTMENT 9"
` • IMPROVEMENTS PERMITI AND CERTIFICATE OF COMPLETION
OTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatm nt and Disposal Rules (10 NCAC 10A .1934-.1968) J Permit Number
Namesr1L'r .��',��GG�/„�„r%� Date �,4,
Location 'r .,� c %�� �c, �', ,r' : %, ✓ / / -
-'Subdivision Name
Lot No.
Sec. or Block No.
Lot Size
House
Mobile Home Business Speculation
No. Bedrooms No. Baths
No. in Family �S
Garbage Disposal
YES p NO 2r
Specifications
for System:
Auto Dish Washer
Auto Wash Machine
YES NO fl
YES NO
�'t
p
Type Water Supply
_
'This permit. Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
s
"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: 704-634-9985.
Final Installation Diagram:
�r
System Installed
Certificate of Completion —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.
�'.. APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT .0
4- Davie County Health Department
Environmental Health Section ec[r�tt,
R O. Box 665 �GVG
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By (/f22 1101' ,h
2. Address,1_0� 51 44a—,
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair .
b) Privy Conventional�Other Type
Ground Absorption
Home Phone
Business Phone '� 2 (e
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House 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
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 garbage disposal
lavatory 4 showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approvedl Yes No
9.,a) Property Dimensions
b) Land area designated to building sit
c) Sewage Disposal Contractor 4f4 ► - of
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 knowledge. d x
? r Z'
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FO LIANCE WITH ALL STATE A(/CAL LAWSMP
Allow 5 days for processing
Directions to property:
'G i-.�
A1v 1?41 L
/
DCHD (6-82) I /U k� ✓ V L ��
ek- df
ahs -
t
FOSTER
480
101
AXLE
l
o ~ �O
A° 0A
b j
_IPS
N 040 31' 27"W t
55.65 t
BENT 3
EIP NIP 313.48 TOTAL
40.09 39.91 152.13 192.06 TOTAL
,r
o° e
2)
ti° e I
+CIO
AREA = 2.4'64 AC'
( INCLUDES S.R. 162Q,-, R� ) I
i
F 1 �
1,
418.06
s 8-!o ca' 00" w
-7 , l- P
i
i
4
r
AXLE
l
o ~ �O
A° 0A
b j
_IPS
N 040 31' 27"W t
55.65 t
BENT 3
EIP NIP 313.48 TOTAL
40.09 39.91 152.13 192.06 TOTAL
,r
o° e
2)
ti° e I
+CIO
AREA = 2.4'64 AC'
( INCLUDES S.R. 162Q,-, R� ) I
i
F 1 �
1,
418.06
s 8-!o ca' 00" w
-7 , l- P
I
, DAVIE COUNTY HEALTH DEPARTMENT
-4 Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name_
Address
FACTORS
(
Y�
AREA 1 AREA 2
Date
Lot Size
AREA 3 AREA 4
1) Topography/ Landscape Position
�,
S
S
S
(,PS)
PS
PS
PS
U
U
U
2) 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
1) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
Available Space
S
S
PS
S
PS
S
PS
U
U
U
►) 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
UCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title
Date