339 Baity Rd (2)1
b DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION !
*MOTE: 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 ., /�; - y;.,� Date j'`'r ` 3''r
Location , /`�/ j%- �, t=,% �%/ /', �� �'s� 4Z" -P/ ✓'� r.�, `
Subdivision Name
Lot No
Sec. or Block No.
Lot Size %;' House Mobile Home _ Business Speculation
No. Bedrooms— No. Baths No. in Family_
Garbage Disposal YES ❑ NO p--
Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES NO ❑ ��'�� ` ,> ` _
Type Water Supply ,1�4
*This permit Void if sewage system described below is
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:
Svstem Installed by
Certificate of Completion / �.f/ r 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 ,; P
Davie County Health Department /v
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By 0 In 02 ij 4,P
2. Address ' S�, nsr l Urn (�pL,%�s�i"le
3. Property Owner if Different than Above
Address
4. Permit To: a) Install v Alter Repair
b) Privy Conventional Other Type
Ground Absorption ,
Home Phone 992-3,090
Business Phone
c) Sub -Division Sec. Lot No
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 0 -13 .
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions l*QL /.ft d P &!S-- k qQ
Bed Rooms 42.— Bath Rooms —J— 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
b) Land area designated to building site (stn iq
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 knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
tri✓� �D/ /��� , J6 f�asf the �����mn cr��k �br,'GIye;
iQoa cl /1�um:bel`-
�U
one 6n %e �� on O�i�� ���4�. —7--,4-
a,
7--fa- n, d i e- ve l od •
DCHD (6-82) ,
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
• R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name/� Date y
Address Lot Size 6h�
CAPTnGC AREA 1 ARFA 9 AREA 3 AREA 4
Topography/ Landscape Position
PS
��
S
S
U
U
U
!) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
PS
S
ES �
S
S
PS
U
<f
CfF>
i) Soil Structure (12-36 in.)
Clayey Soils
S
PS
S
PS
S
P
S
PS
U
�) Soil Depth (inches)
S
S
PS
S
PS
S
PS
U
i) Soil Drainage: Internal
S
PS
S
S
PS
S
PS
U
External
S
PS
S
S
PSPS
S
U
i) -Restrictive Horizons
') Available Space
pif,
&�)
S
S
PS
U
U
U
3) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
f) Site Classification
/
U—UNSUITABLE
Recommendations/ Comments:
Described by __ _0�zz
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title Date
1
C