2158 Hwy 158 (2)k r 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
Name Date µ ,, 7 ('",, c t=; 3803
*
Location �' a r- .,i ��r /,,:�- /` 1 i
Subdivision Name Lot No. Sec. or Block No.
Lot Size ! r' House Mobile Home Business Speculation
No. Bedrooms _ No. Baths --T No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System
Auto Dish Washer YES Q NO ,✓ c ' r �` -' , ;� ��,.
Auto Wash Machine YES,n NO ❑
Type Water Supply
r-
*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 t4
r
Certificate of Completion A���ti(,�,� Qfl 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.
Name—
Address
GA r'TADQ
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARCA i
Lot Size
AREA 9 ARFA 3 APPA A
2)
5)
6)
8)
Topography/ Landscape Position S S S S
PS PS PS
U U U
Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
`-� U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils j PS PS PS
U U U
d) Soil Depth (inches) S S S
5P3) PS PS PS
U U U U
Soil Drainage: Internal S S S
PS PS PS PS
U U U
External S S S S
PS PS PS PS
U U U U
Restrictive Horizons C-F�
,)'Available Space S S. S S
PS PS PS
U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by _
SITE DIAGRAM
DCHD (8-82)
S—SUITABLE PS—Provisionally Suitable
Title Date
U—UNSUITABLE
Recommendations/ Comments:
Described by _
SITE DIAGRAM
DCHD (8-82)
S—SUITABLE PS—Provisionally Suitable
Title Date
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department , 2�
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Reques ed By ` 4 .v, Business Phone
2. Address Jt" L x s -b-.-' k Al
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
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions y'/"" &a
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 showers ✓ washing machine ✓
dishwasher sinks
8. a) Type water supply: Public `� Private Community
b) Has the water supply system been approved? Yes ✓ No
9. a) Property Dimensions �r� ,�T- 1 z� - �,,� r- s, d .- iL a z> #�;St _K 12- ° - < «fis a9 f f3
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 kn ledge.
7Z/1 3 ` q 5—
Date IOwner Signa ure
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Q —Z 4v1_S/.5-./ 34/,t _�2 �' /�-'"O." /110uGSV//,/L
� Ort/ 4 �Cfi �r,d O )C-- Irve
T:_ Sa/_,
DCHD (6-82)