P4478 Hwy 158cif
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'��;1/�-
�T.-7 +
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home ��� Business Speculation
No. Bedrooms —7� No. Baths No. in Family Z
Garbage Disposal YES ❑ NO Specifications for System: ,
Auto Dish Washer YES ❑ NO 0 -
Auto
Auto Wash Machine YES ❑ NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
F
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.
J
Final Installation Diagram: 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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
RECEIVED AUG 2 p 1986
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone..9-3727 %
1. Permit Re u�ted By
I L n1 Business Phone —35 377
2. Address , Z_'Mo ' ;ga�*LLe,%1 .�,rr✓; 504
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 Homes
r Industry Other
b) Number of peopl
6. a) If house or mobile home, state sizeR f home and number of rooms.
House Dimensions 6 0'X /2- j
Bed Rooms Bath Rooms Den w/Closet�l�
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 2- urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply sy tem been approved? Yes No�
9. a) Property Dimensions -Y7 C r ce�'s
b) Land area designated to building site
c) Sewage Disposal Contractor -Q
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.
$6
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: _
� ass
'J7 `
r
DCHD (6-82)
Name_
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
AREA 1 AREA 2
Date
Lot Size
AREA 3
AREA 4
1) Topography/ Landscape Position
SS
S
S
PS
PS
PS
U
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
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U,
) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
U
�) Restrictive Horizons
Available Space
S
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U.
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS -Provisionally Suitable
Recommendations/ Comments:
Described by Title Date
SITE DIAGRAM
DCHD (8-82)