P4238 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 Date
J1
Locations L= '
Subdivision Name Lot No. Sec. or Block No.
Lot Size T%_%T f?!' House Mobile Home _ Business __ Speculation
No. Bedrooms Z No. Baths No. in Family
Garbage Disposal YES :p NO
Specifications for System:
Auto Dish Washer. YES NO
Auto Wash Machine YES NO
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by rte -
*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 b
y ✓ �.
010 CtA-,-
ODO
(a
Certificate of Completion — Daae•
*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.
1. Permit
2. Addre;
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department /
Environmental Health Section �/� (/
R O. Box 665 3
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
3. Property Owner if Different than Above
Address
4. Permit To: a) Install �Aiter Repair
b) Privy Conventional L�Other Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home usiness
IndustryOther
b) Number of people /
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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
lavatory
uri
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 or- --
garbage disposal
washing machine
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?
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:
1-
DCHD (8-82)
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date " Z,&fz—L�Z
Lot Size 44)
AREA 1 ARFA 2 ARFA:3 ARFA d
1) Topography/ Landscape Position
U
U
S
PS
U
S
PS
U
') Soil Texture (12-36 in.) Sandy,
Loamy, Clayey,. (note 2:1 Clay)
p—jp
U
U
S
PS
U
S
PS
U
1) Soil Structure (12-36 in.)
Clayey Soils
U
U
S
PS
U
S
PS
U
g Soil Depth (inches)
PS
U
S
PS
U.
S
PS
U
i) Soil Drainage: Internal
S
—
U
S
PS
U
S
PS
U
External
—U
Tj
S
PS
U
S
PS
U
i) Restrictive Horizons
Available Space
PSPS
C::
U
S
U
S
PS
U
1) Other (Specify)
S
PS
U
S
PS
U
S
Ps
U.
S
PS
U
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9) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE PS—Provisionally Suitable
Described by Title
SITE DIAGRAM
DCHD (6-82)
Date ,��/