2485 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
Sewage Treatment and .Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name (,OitLiflrh 6A 137uIrNs Date 7_f -`'�`i E��r; . 569
Location !nC)! N CM. L`GF-r- /�CrGOSS / 2dM ��tl/ NUirSY/c r _
i
Subdivision Name Lot No. Sec. or Block No.
Lot Size 2b0 x Zpo House Mobile Home _✓ Business Speculation
No. Bedrooms Z No. Baths No. in Family 'Z -
Garbage
Garbage Disposal YES p NO E�— Specifications for System: /oD0 G,,11,
Auto Dish Washer YES NO E] i //
Auto Wash Machine YES NO -p ZOo X S7a1,J£
Type Water Supply �a :_ - f� �^ Ga�vc/zf-7�
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
*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
Certificate of Completio ' Date
T»-'z�
"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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
NamelC(/t GA'!?:::! 1 Date
Address R- - Ca 6"'x 3W? Lot Size ? XZo o
/(/l-�cresvtc"�L QVC 7,7025-
Gerrnac ARFA i ARFA 9 AREAS AREA 4
Topography/ Landscape Position
(ts$�PS
-4u
S
S
PS
U
U
!) Soil Texture (12-36 in.) Sandy,
P
S
S
PS
S
PS
Loamy, Clayey, (note 2:1 Clay)
U.
lT
U
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
S
P
S
PS
S
PS
U
U
U
G) Soil Depth (inches)S
S
S
S
�-
PS
PS
U
U
U
i) Soil Drainage: Internal
S
S
S
/ S
PS
U
External
S
S
S
S
PS
PS
U
U
U
i) Restrictive Horizons
1) Available Space
S
PS
S-
PS
S
PS
S
PS
U
U
U
U
3) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
�) Site Classification
U—UNSUITABLE S—SUITABLE Q PS—Prbvisionaliy Suit ble
Recommendations/ Comments:
Described by Title�`�147�u�'"
SITE DIAGRAM
DCHD (6-62)
Date cS-- ff. .
f APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT ,g� .M•
Davie County Health Department 1 P
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone Z112" 6 V%Z
1. Permit Requested By W �►- 0YAP,, �u�e Ems Business Phone
2. Address- 1, �Q- ��12� of j%SVi ll� C.� �'10a$
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 Homed Business
IndustryOther
b) Number of people oa
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions i8 I Leo
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
lavatory
showers
dishwasher sinks
8. a) Type water supply: Public_ Private Community
b) Has the water supply system been approved? Yes - No
9. a) Property Dimensions A00 F-4-• X -200 F4-
garbage disposal
washing machine
b) Land area designated to building site
c) Sewage Disposal Contractor L1-f1V_M0txDr
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.
u 6 , �9'!Wq 't 1 66Z1&25a_
ate Ow er Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
..'2
Es 2
DCHD (6-82)
/Ube .-orl. JDA AvwaAa '� Ak d'o 1\e-
-�0 &'DI N Ixs"