P4007 Hwy 801Sw DAVIE COUNTY HEALTH DEPARTMENT
t 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
nnT.
NDate
ame
Location
Subdivision Name
Lot Size
Lot No
House L-' Mobile Home
Sec. or Block No.
Business Speculation
No. Bedrooms
No. Baths .�;
No. in Family
r
Garbage Disposal
YES ❑ NO ❑%
Specifications
for System:, -
Auto Dish Washer
YES Ej NO ❑
i ,�
,- :. ,,! .�_i`'/_ r ;.
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
`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 c=.n'1919L
J r
t
a\
i
E
j ` " 411,
Certificate of Completion t Date .-7, �
"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.
r
i
Improvements permit by
`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 c=.n'1919L
J r
t
a\
i
E
j ` " 411,
Certificate of Completion t Date .-7, �
"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.
Name_
Address
f�
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
e2yZe,
,
Lot Size /i9(5-7
Ger.Tnac AREA I APPA 9 ARFA 3 ARFA A
Topography/ Landscape Position
S
S
S
PS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
SS
S
S
S
Loamy, Clayey, (note 2:1 Clay)
4'.�
PS
PS
PS
U
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
d�>
PS
PS
PS
U
U
U
U
G) Soil Depth (inches)
S
S
S
S
PS
PS
PS
qP
U
U
U
Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
ExternalS
S
S
A5
PS
PS
PS
U
U
U
U
i) Restrictive Horizons
') Available Space
S-
S
S
PC
PS
PS
PS
U
U
U
U
3) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
I) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title Date
(
APPLICATION FOR SITE, EVALUATION/IMPROVEMENTS PERMIT
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.
�1
,,yy�� Home Phone 99g-�lyv
1. Permit Requested By %�� QOAuQIV,111PK. Business Phone 57 .4,W �-
2. Address t�2 doex 9Y agree IV. C. =;2- 7-70-6
3. Property Owner if Different than Above r nef Aa6ti
Address f% o� 9% /9c�u.lrr�v !'L . �'• 2 no G
4. Permit To: a) Install 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 3
6. a) If. house or mobile home, state size of home and number of rooms.
House Dimensions X 36
Bed Rooms 3 Bath Rooms –2 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 Z urinals garbage disposal
lavatory Z showers washing machine—/,-
dishwasher
achine /,_dishwasher 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) Sewage Disposal Contractor SeA1191-L
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.
.,Q
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
f �g '� 7`o SDl �fi� �Pqf� ��oP�eox:,�afe i yyt`, /es
955 e4 ele,_� (?r2 ee K 80
p c�� i 5 0(� 12ecel � K� Ai11 .�o�I to . s 1� es'cj
� ewe,
/6uG /Yl ort e C1;.e ecP0A g o 2. �h�oe.na�%B•� ,
1, N
�e ko�J ra-
pe,4 yon
$0,1tj;d Yy): Ile.
DCHD (6-82)
- 998-a�ya