P3221 Hwy 601NDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
`Note: Issued in Compliance with G.S. of North Carolina Chapter 130—Article.13c.
Permit Number
T o
Name - nnti '76%b as Mnar Date �L �Ty o3 1221
3 I
Location L Of d - t-'WST_ IV ILa • . R: DAvi4.. Sa (no •:1.. -- cap,)( 30,6-5-#61 :
Subdivision Name Lot No. Sec. or Block No.
Lot Size J45� '�7 53O House Mobile Home ✓ Business Speculation
No. Bedrooms— No. Baths t No. in Family_
Garbage Disposal YES ❑ NO Specifications for System: t oee 0 Ton V --
Auto Dish Washer YES E] NO ij�� o
Auto Wash Machine YES J?r' NO ❑ a �� eco. a `� ��• ���`
Type Water Supply Gst rr
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
;►.,,�,,ttcT Cpl
o
S. -T& -At STITO..»
}
t
i
� y
l '
Improvements perms
by �O M "
*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
01
.416 Pt �
0 0
,L
i
J
i
_,,� q3
Certificate of Completion f�"' Date
*The signing of this certificate shall indicate that the system describe bove has been installed in compliance with
the standards set forth in the above regulation, but shall in NO way, be t en as a guarantee that the system will function
satisfactorily for any given period of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name
JoJones Date
Address Tt+- 5 a4 5,31 Lot Size L/3 -K .SZo
YY1utlt. Z� o2Y
GerrnQc AREA 1 AREA 9 AREA 3
w
AREA 4
Topography/ Landscape PositionS
PS
®
S
PS
S
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
U
U
�) Soil Structure (12-36 in.)
S
S
S
PS
S
PS
Clayey Soils
(0
ds�
U
U
U
U
Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
Soil Drainage: Internal
S
S
S
p
PS
PS
U
U
U
U
External
S
S
�
PS
PS
I) Restrictive HorizonsIc
Available Space
S.
S
PS
S
PS
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
!) Site Classification
P
U—UNSUITABLE S—SUITABLE( � ipS—PFovisionaliy Suitable
Recommendations/Comments: WeAl-- Lek +'U;�;u-- -,%- m S"- <<
Described by Q - Y Title �' CIAA':3S,- Date
,SITE DIAGRAM L, ZabX
DCHD (6-82)
1. Permit F
2. Address
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
By
3. Property Owner if Different than Above
Address
4. Permit To: a nstall Alter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone
Business Phone
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homel:::LfBusiness
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 42 X C
Bed Rooms Bath Rooms Den w/Closet—�—
b) If Business, Industry or Other, State: Number of persons served A/11
What type business, etc. nll�
Estimate amount of waste daily (24 hours) A'A
7. Number and type of water -using fixtures:
commodes urinals' garbage disposal b
lavatory showers / washing machine
dishwasher n sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system een approved? Yes Lf No
9. a) Property Dimensions A 1� 1
b) Land area designated to building site ,• �j
c) Sewage Disposal Contractor 'jam-
42,24 L� Al- � 4-)
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 girvner Signate
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Direction t ro ert :
/2,
DCHD (6-82)