428 Georgia Rdr �l� DAVIE COUNTY HEALTH DEPARTMENT C -
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION1
*NOTE,lssued'in Compliance with G.S. of North Carolina Chapter 130 Article 13c T.
�c Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) / Permit Number
'Name �F��r�,. �/'�/!,•.�-�'f'� 1-�' Date
Location-� �,%� 1 s` f – ,f -' _�' rte"
Subdivision Name Lot No. Sec. or Block No:
Lot Size�Z�*�� House �� Mobile Home _ Business Speculation
No. Bedrooms No.,Baths No. in Family—" —
Garbage Disposal YES ❑ NO p! Specifications for System:
Auto Dish Washer YES NO
Auto Wash Machine YES g N,& ❑ o
T e Water Supply/CU' ���ql vtll"',
Y�
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
C/
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"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.
x
Final Installation Diagram:
System Installed by
Z✓
f�
Certificate of Completion Date
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'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
Davie County Health DepartmentQ 0% UP
Environmental Health Section Ccell Q
P. O. Box 665 R`
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT'HAS BEEN ISSUED.
1. Permit Req
2. Address —
Home Phone
ness Phone __94kaz/"
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
. ` Industry Other
b) Number of people `�
6. a) If house or mobile home, state size of ome and number of rooms.
House Dimensions / (D U D
Bed Rooms zg 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 19- urinal
garbage disposal
lavatory.�showers .2 -washing machine
J
dishwasher / sinks
8. a) Type water supply: Public Private—� Community
b) Has the water supply systerp been approved? Yes No
9. a) Property Dimensions____ _1600 X w jo
b) Land area designated to building site __ _h ho=J r--4 e- op- 6,'Qoctaga.
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.
Date
Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALLSTATE AND LOCAL LAWS.
Allow 5 days for processing
Directions to property:
/ dr Ick
111 14 ovy
I t p _719 I -L ,
r
S %� N
DCHD (6-82)
619
Name_
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
//v
FA(:Tr)RS AREA 1 ARFA 9 AREA 3 ARFA A
t) Topography/ Landscape Position
9)
S
S
S
PS
S
PS
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PS
S
PS
U
U
3) Soil Structure (12-36 in.)�
Clayey Soils
P,Si
S
PS
U
S
PS
U
1) Soil Depth (inches)
S
PS
S
PS
S
PS
U
U
i) Soil Drainage: Internal
Ll�
S
PS
U
S
PS
U
External
p
11
S
PS
S
PS
U
'Ip��/
U
U
i) Restrictive Horizons
Available Space
pS
—PS
S
PS
S
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6.82)
S—SUITABLE F�S—Provisionally Suitable
Title S� - - Date
A-21
P'