P3744 Hwy 801NDAVIE 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 Jl-: '— i� -,;,; 3!44
J ��
Location zeal ;. �: s • _
Subdivision Name Lot No. Sec. or Block No.
Lot Size / e) dr
House
Mobile Home Business Speculation
No. Bedrooms �
_ No.
rte,.:;,:'
Baths _
No. in Family
Garbage Disposal
YES
❑ NO ❑
Specifications for System: 1600
Auto Dish Washer
YES
❑ NO ❑
t `�`i 1 U ` - - 4
Auto Wash Machine
YES
❑ NO ❑
,X ?
Type Water Supply
�_�, r E 1.
--
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
CN, 'rN _ .
Improvements permit bye+
*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
ayC i Yeo Se! L - J kC-
ku Cw.V-UC wt sC4.s�„14 .
it Z
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—°
A
Certificate of Completion Date - r 2
v
*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
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name- ,icupaD
A, I v `ONiCfLd Date 9—G
-
Address 2T (0 Lot Size
�OGKS�iCI� NC_ '2-7 0
E
FACTORS AREA 1 AREA 2 AREA 3 AREA d
1) Topography/ Landscape Position
p<--s:j-
(�D
n
PS
PS
PS
U
U
U
U
?) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)3
,�S
�
SPS
3) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
US
�PS
�PS
� PS
1) Soil Depth (inches)
S
S
S
S
PS
PS
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
(=>
PS
External
S
S
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
I) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification -
v L
r—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Com--I- SfA1ZC14&- OVErZ �d A-�• ^ N6
Described by 5PEA-S
SITE DIAGRAM
DCHD (6-82)
Title 57A-yJ'7 kX/Aj
Date C°
w
. APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT G,L�JA
Davie County Health Department a
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone r7oLl - k19a- 7a/3
1. Permit Requested By r c iness Phone
2. Address
3. Property Owner if Differ nt than Above --1 rV_t1_eJ__
Address
4. Permit To: a) Install..tZ Alter Re2>40the'r
b) Privy Conventional Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile HomesZ Business
IndustryOther
b) Number of people e7
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions l a V 6
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 urinals
lavatory showers J
dishwasher sinks
8. a) Type water supply: Public Private_ Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions M of e ti - v.
b) Land area designated to building site nv Q C 1,4cj?c,
c) Sewage Disposal Contractor o/� e •C All se r
10. Do you anticipate any
garbage disposal
washing machine
ons or expansions of the facility this sewage system is intended to serve?e�L
What type? L/c AAP 11 n; -Q LO .h �„� .0 4nRcre)P '"01121 L4 In K,
* Do16� WIMP
This is to certify that the information is correct to the best of my knowledge.
Date Owner Signatur
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LA
9
Allow 5 days for processing
Directions to property: I„� r� nraok o�-C"^A oN)�o)
y r poSS/� IP-X5e C•+ / ' eA e _pY, j be /1e - o Y!1 � r o � io c �e.Ck
9
-)40,,9 9 g -, Ll pi,
DCHD (6-62)
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