P4417 Fork Bixby Rdf a DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
'rI OTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
gewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name Date ���f 1^ 17
Location �!"> r✓�'` ,..%= �l%r`�/,—�'' s ,14�s-,
Subdivision Name
Lot No
Sec. or Block No.
Lot Size House Mobile Home,_ Business Speculation
No. Bedrooms No. Baths J No. in Family '} _.
Garbage Disposal YES ❑ NO ❑_- Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES NO ❑
Type Water Supply /L., !r'
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
"Contact a representative of the Davie
9:30 A.M. or 1:00-1:30 P.M. on day
Final Installation Diagram:
Improvements permit by
l
Health Department for final inspection of this system between 8:30-
fetion. Telephone Number: 704-634-5985.
System Installed by
(
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.
j
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
�= Davie County Health Department
Environmental Health Section '
P. O. Box 665 RECEIVED JUN 2 186
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
/ Home � W69 b i
1.. Permit Requested By (1 J4 -e- Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair`��
b) Privy ConventionalL Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House obile Home Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions -3 0�q -i- -'� '�
Bed Rooms— hath 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 showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community -
b) Has the water supply system been appprpved? Yeses N
9. a) Property Dimensions 7 a���
! Z 7
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 informati is c rhe t to the best of my k of
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
�- -D14� d,,114
DCHD (6-82)
' DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date —
Address Lot Size
FACTORR ARFA 1 AREA ? AREA 3 ARFA d
1) Topography/ Landscape Position
PS
S
�
S
PS
S
PS
U
U
�) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
c
S
rf rs-3
S
PS
S
PS
U
U
1) Soil Structure (12-36 in.)
Clayey Soils 0
S
<�p�S�
S
S
PS
S
PS
U
U
U
1) Soil Depth (inches)
r (4
0'
S
PS
S
PS
U
U
) Soil Drainage: Internal
S
S
PS
U
S
PS
U
External
®'
PS
PS
S
PS
S
PS
U
U
U
U
1) Restrictive Horizons
Available Space
�g
S
-PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
--IS"
�'
� t
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAI
DCHD (6.82)
S—SUITABLE (,,"PS—Provisionally Suitable
TRIP Date