P4352 Hwy 158• 4�: 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-.19/68) Permit Number
Name �/, ,�,i%P ,s :r ✓ Date 'C /;'� t rc 9
Location .�`r✓'� r%i.'�7',l//'' ! iii .%.,� =�`r /' 1 ,<..�; '�j
Subdivision Name Lot No. Sec. or Block No.
Lot Size _,.�( House Mobile Home ��� Business Speculation
r'
No. Bedrooms _ No. Baths No. in Family f —
Garbage Disposal YES ❑ NO B'
Specifications for System: f
Auto Dish Washer YES NO ❑ ��^�7.' �:-;
Auto Wash Machine YES NO •❑
Type Water Supply 11-�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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 Installed by
co S j -
moo -61
1�
CerU ica e o omp etion `-T-J`r' 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.
� 1
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 1
1. Permit Reque!530 By ���Y���.P ��� Business Phone
2. Address 9��A'�•�AL��C
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional_s��Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home —L-1116siness
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions-- b
Bed Rooms— Bath Rooms_,, Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
7
What type business, etc.
Estimate amount of waste daily (24 hours)
Number and type of water -using fixtures:
commodes
lavatory
urinals garbage disposal
showers
washing machine
dishwasher ink
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes &-" o
9. a) Property Dimensions f -
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 iscor ct to the best of my knowledge.
6vazzze�� - IDatewner Signature
OWNER IS SOLELY RESPONSIBLE FOR CO PLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
i
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name-- �'Date
Address Lot Size-11f(f
FArTnP.R ARFA 1 ARFA 9 ARFA :1 APPA A
1) Topography/ Landscape Position
S
S
S
PCS
PS
PS
U
U
'.) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
S
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.),,i
ck3
S
S
Clayey Soils
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
PS
PS
U
U
U
) Soil Drainage: Internal
PS
S
PS
S
PS
U
U
U
External
S
PS
S
PS
S
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
S
S
pg
I
PS
PS
U
U
U
1) 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
DCHD (8-82)
S—SUITABLE PS—Provisionally Suitable
Title �U Date, -5/6 —