P3126 Hwy 601SDAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*Note: Issued i i Compliance with G.S. of North Carolina Chapter 130—Article 13c.
Permit Number
Name ''� _ �` ~� Date
Location
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 p NO p�
� Specifications -for System:
Auto Dish WasHer YES Q NO ,0 /�r jl , t '
Auto Wash Machine YES p NO E]
Type Water Su ply _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by
*Contact a rep sentative 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:
Certificate of Completion -� 11n p,� - - Date f 1- K - E -
*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 fo� any given period of time.
1. Permit Re(
2. Address _
3. Property C
Address _
4. Permit To:
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davi!. County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone q 17117 Z7
Business Phone 69 1� 6 ///
if Different than Above
a) Install --L 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 Home Business
IndustryOther
b) Number of people 7
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed ooms l Bath Rooms— De wyCloset
b) If Busin ss, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 hours)
7. Number a�d type of water -using fixtures:
commodes Urinals
garbage disposal
lavatory showers washing machine /
dishasher sinks
8. a) Type w ter supply: Public Private Community
b) Has th water supply system been approved? Yes.ZNo
9. a) PropeDimensions
b) Land lea designated to building site
c) Sewag�Ij Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What typ ?
This is to certify that the information is correct to the best of my knowledge.
IA 'dj
Date 0 Owner Signature
WNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to broperty:
601-
DCHD (6-82)
Name a
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
AREA 3 AREA 4
0
AREA 1 AREA 2
�) Topography/Landscape Position S S
PS PS PS
U U U U
2) Soil Texture (12-36 �'
in.) Sandy, S S S S
Loamy, Clayey, ( ote 2:1 Clay) 2 PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey y Soils Cf� PS PS
U U U
4) Soil Depth (inches) " C 1 � S S
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S
S PS PS PS
U U U U
Ex ernal S S
PS PS PS PS
U U U U
6) Restrictive Horizc ns
Available Space S S S
PS PS PS PS
U U U U
1) Other (Specify) S S S S
PS PS PS PS
U U U U
1) Site Classificatioll
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
iecommendations 'Comments:
Y/
)escribed by Title w/ Date `� l
)ITE DIAGRAM
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