3547 Hwy 801SDAVIE 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 �Ox%! YOVA16--Date Z ZZ – , �L r, 0
� ;� '3457
Location ���I /1sT Lf F7 chi- 06 loi ter' CfFr fias7 nuc��N Civ -tai/
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home — Le""' Business Speculation
No. Bedrooms
No. Baths Z
No. in Family 2' _
Garbage Disposal
YES ❑ NO .Q�'
Specifications for System: /000
Auto Dish Washer
YES p NO ❑
/
zoo /z
U
Auto Wash Machine
YES NO ❑
k 3 x
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Type Water Supply
Wf "
---
�- 1 s, . cnN��r ��
-zoo X3107- `.
"This permit Void if sewage system described below is not installed within 36 months from date of issue.'
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Improvements permit byt"�'�
"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�,7,W-634-5985.
Final Installation Diagram: System rnstalld-d000l
aY &Dpc
1 \
Certificate of Completions07–
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.
x
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name LOiel A'Vwc' Date
Address eT• 2 '�?X 44/r Lot Size—Z A-C-
��✓itni� /tom. 27ca6
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/ Landscape Position
a
(D�
S
S
PS
PS
PS
PS
U
U
U
U
�) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
(9
cb
PS
PS
U
U
U
U
I) Soil Structure (12-36 in.)�',��--�
S
S
Clayey Soils
?�
(jp
PS
PS
U
U
U
i) Soil Depth (inches)
S
S
S
S
PS
PS
U
U
U
U
i) Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
U
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
S
S
S
PS
PS
PS
PS
U
U
U
U
)) Site Classification
<—
U—UNSUITABLE S—SUITABLE
Recommendations/Comments:
Described by Title
,SITE DIAGRAM
DCHD (6-82)
ionaliy Suitable
`!''`• Date
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT 2.
Davie County Health Department
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 952- 43G0
1. Permit Requested By - Business Phone t034� - �,q t
2. Address NImnCA ., N.
3. Property Owner if Different than Above
Address RAKxmr o
4. Permit To: a) Install t✓ 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 Homed Business
IndustryOther
b) Number of people -a-
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions Nr X 90
Bed Rooms a- Bath Rooms—c2 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 a- urinals 0 garbage disposal
lavatory. 8- showers washing machine
dishwasher O 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 c- mi la nCAA-1n Dg-�j VA Q n SOI
c) Sewage Disposal Contractor I
,, /
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? 'v O
What type?
This is to certify that the information is correct to the best of my knowledge.
Date wner 6ignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
M'"
DCHD (6-82)