P4521 Murphy Rd.. -.. ✓ � :.w+t'. ..e. r wrs w. A ... a.. a... ....A'.. t ... r.. n .u.. ..':r .« ` 14. '�..A v' yP- r «• .... - _
DAVIE COUNTY HEALTH DEPARTMENT
od 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
Location'7�.�7
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home t Business Speculation
No. Bedrooms - S� No. Baths ' No. in Family
Garbage Disposal YES p NO p--" Specifications for System:
Auto Dish Washer YES NO [:]/ ,/ �~'' ll )
Auto Wash Machine YES NOfv/
� v
-
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
J
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 eA ^ n
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.
Name_
Address
FA r.Tr1 RC
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
APPA 1 APPA 9
Date
Lot Sized �l2 e
ARFA R APPA A
2
) Topography/ Landscape Position S S S
eb PS PS PS
U U U U
) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS PS
U U U
A
8)
) Soil Depth (inches) S S S
pS PS PS PS
U U U
) Soil Drainage: Internal S S S
pS PS PS PS
U U U
External S S S
PS PS PS
U U U
�) Restrictive Horizons `
Available Space S S S
4)s
PS PS PS
U U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification ,
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title
SITE DIAGRAM
DCHD (6-82)
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title
SITE DIAGRAM
DCHD (6-82)
• RECEIVED SEP
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT 2 9 j',)36
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.
1. Permit Requested By
2. Address #%8A4'G
3. Property Owner if Different than Above AM J1 A4 4�u
4e, Address
4. Permit To: a Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone M_ 7_11S%SWs
Business Phone 91? — 78i/- 71YO
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOt er
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions LV
X �� I
Bed Rooms 3 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 z urinals garbage disposal
lavatory showers z washing machine
dishwasher sinks 3
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions Sao 14 6 l G
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? Nlo
What type?
This is to certify that the information is c rrect to the best of my knowledge.
Date Owner Sig ature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: _ `fitic"
r,a" Ca" 'r"
(Sro) 1350 Oztst
DCHD (6-82)