P3701 Hwy 601SDAVIE 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 l6I��y Date �� 7 !- a l se '117 Q 1
Location 60/ -S Ota! 2lc,F,T f /;lief L<£�afrt a`��uTf� ys�ti�x.�r <<ir/.r2
Subdivision Name Lot No. Sec. or Block No.
Lot Size / !!� House '"'' Mobile Home _ Business Speculation
No. Bedrooms 3 No. Baths No. in Family 2.- _
Garbage Disposal YES ❑ NO
Auto Dish Washer YES TNO ❑ Specifications for System:/pp;���l%-
Auto Wash Machine YES NO -❑ %300 ''{
Type Water Supply e0&A17-/ ----- eax' 0"
"This permit Void if sewage"',Vstem described below is not installed within 36 months from date of issue
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permit by � u S -
"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 -?,) a C 0 C K�-
c
J Certificate of Completion ```j }� ^��� Date 1- i �' " Y t)
'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
Name �-D' p f: Date
Address Z� e14`16i* S7 -C
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Lot Size S��
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I:Ar.TnRc APPA 1 ARFA 9 ARFA 3 AREA A
Topography/ Landscape Position
2)
3)
4)
5)
S
S
PS
PS
PS
PS
U
U
U
U
Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
(9)P3
PS
PS
U
U
U
U
Soil Structure (12-36 in.)
S
&
S
qrP
S
PS
S
PS
Clayey Soils
U
U
U
U
Soil'Depth (inches)
S
S
S
S
PS
PS
U
U
U
Soil Drainage: Internal
S
6
S
f'S
S
PS
S
PS
U
U
U
U
External
®
2S7
S
S
PS
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
Available Space
S
S.
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
.0
U
U
►) Site Classification
Q S
p
t
U—UNSUITABLE S—SUITABLE CPS
Provisionally Su
Recommendations/ Comments:
Described by �VXZ5-" TitleDate
SITE DIAGRAM
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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.
1. Permit Requested B
2. Address `L3 C_ -'A u»c—k S7,,,, 04 c, Az r/ IZe
3. Property Owner if Different than Above
Arlriracc
4. Permit To: a) Install Alter Repair
b) Privy Conventional Other Type
Ground Absorption
Home Phone 6 b
Business Phone /-34 —
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: oouse Mobile Home Business
In ustryOther
b) Number of people
mobile a f house r mobile home, state size of home and number f roo s.
200 ->n f �- .i G
House Dimensions / o owt� '
Bed Rooms 3 Bath Rooms Den w/Close /��f��z�
b) If Business, Industry or Other, State: Number of persons served V
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 Com unity �
b) Has the water supply system been approved? Yes. f�o
9. a) Property Dimensions / &E&,
b) Land area designated to building site
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of he facility this sewage system is intended to serve? �o
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: /n
DCHD (6-82) •,
M/