P3764 Hwy 801S• DAVIE 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 ar�d Disposal Rules (10 NCAC 10A .1934-.1968) / Permit Number
Name �' '�, tel' Date / � i �1,/ if 3764
i 2-
Location e C -I i
Subdivision Name
Lot No. Sec. or Block No
Lot SizeHouse Mobile Home _ �='Business Speculation ! No. Bedrooms No. Baths __ No. in Family _
Garbage Disposal YES ,E] NO [a-' Specifications for System: f
Auto Dish Washer YES q NO ❑ /
Auto Wash Machine 'YES [7] NO
Type Water Supply / F,...✓
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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.
119 17
Final Installation Diagram:
System Installed by
Certificate of Completion
'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.
et
DAVIE COUNTY HEALTH DEPARTMENT 6'V , fa
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: -Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment/a d Disposal Rules (10 NCAC 10A .1934-.1968)-" % Permit Number
Name r/ %%s �/ Date , �i / �� t .5 S 1
„ r'� �,
Location � /may /y --
J
I
Subdivision Name Lot No. Sec. or Block No.
Lot Size �!;� House Mobile Home _ �'� Business Speculation !�-
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES j NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Ire
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.
,i
Final Installation Diagram:
System Installed by—
Certificate
y
Certificate of Completion =��� Date -`lam
*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.
H
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
2. Address
)c
Home Phone ? S 8" F :3;z t4
Business Phone 9 4 9 -'V 3 3 yL
3. Property Owner if Different than Above /7'.'
Address ocl� i e e M IQ -e_
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 vBusiness 2
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms 2— 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
urinal
showers
garbage disposal
washing machine
dishwasher sinks
8. a) Type water supply: Public A:/ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ���i%'f�
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:
DCHD (6-82)
Address
is✓
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
AREA 1 AREA 2
Date
Lot Size��
AREA 3 AREA 4
Topography/ Landscape Position
S
S
S
P
PS
PS
PS
U
U
U
U
'.) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
(RS >
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
PS
U
U
U
1) Soil Depth (inches)
S
S
S
PS
PS
PS
PS
U
U
U
) Soil Drainage: Internal
S
S
S
PS
PS
PS
U
U
U
U
External
S
S
S
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
S.
S
S
PS
PS
PS
U
U
U
1) Other (Specify)
SS
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
Described by —
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—
Title ,>T Date