P3385 Lybrook RdDAVIE 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 EL �- ' `t2
u
Location =a �� 6620 i C %)eOOC_ C;QICK s 1 —
t
Subdivision Name
Lot No
Sec. or Block No.
Lot Size On (�S�
k c -
House `"� Mobile Home
_ Business _ Speculation
No. Bedrooms _
No. Baths 2-- No. in Family
Z —
Garbage Disposal
YES
NO ❑
Specifications for System: /Z 5-0 C- t.cOAJ TA
'k -
Auto Dish Washer
YES
NO E
11 1 tj
7-00 x -3 x /9 S! -W41`.
Auto Wash Machine
YES
NO F
Type Water Supply
�'�at�.r,-'
�t ---
!)-- e6,v ori aw.,Clz c.f
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
. f paow -
Improvements permit by
i
CaVz,R- yV� A-,/ryv�urh
S.
*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..Fgjy\� 00,00AIZE i -
Certificate of Completion Date
.The signing of this certificate shall indicate that the system descri- ed 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
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
�KN24����
Name Date
Address Lot Size
FAr:Tr1RS AREA 1 AREA 2 AREA 3 AREA 4
2)
3)
5
6
8)
Topography/ Landscape Position CD S
PS PS PS PS
U U U U
Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS & PS
U U U U
Soil Structure (12-36 in.) S S S
Clayey Soils P ft PS
U U U
) Soil Depth (inches) S S
PS PS PS PS
U U U U
) Soil Drainage: Internal Q S ___— ._..___ –� G� S
S PS PS PS
U U U ICI r
External ' V5 S
PS PS PS PS
U U U U
) Restrictive Horizons
Available Space S S. S S
PS PS PS PS
U U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE -PS—Provisionally Suitable
Described by� Title
SITE DIAGRAM
DCHD (6-82)
Date /J
U—UNSUITABLE
Recommendations/ Comments:
S—SUITABLE -PS—Provisionally Suitable
Described by� Title
SITE DIAGRAM
DCHD (6-82)
Date /J
1. Permit F
2. Address
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.
- A40 " ,+?o.,a
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional they Type
Ground Absorption
Home Phone—
Business Phone
�iii4orr Z7o
c) Sub -Division Sec -- Lot No.
5. System used to serve what type facility: Hous Mobile Home Business
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 P-- urinals
lavatory
p2.
showers .2-111
garbage disposal
washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? YesL-- No
9. a) Property Dimensions o2 �4 '� 130 Y_ a �- L x
b) Land area designated to building site
c) Sewage Disposal Contractor `fA it4; �J_' A -IL
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
G I fS
What type?
Q This is to certify that the information is correct to the best of my knowledge.
�?Xf-
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
&-o c e— %G f �' 11. / &
DCHD (6-82)
6-- �
LTH DEPARTMENT
TAALTH SECTION
VALUATIOV
DATE
LOCATIO T S::�2 Z455�z�
r
LOT SIZE /��`' S
TOPOGRAPHY:
SOIL TEi,TURE :
SOIL STRUCTURE:
DEPTH: �' A
RESTRICTIVE HORIZONS: /Zc*�jfi.�(' �......._ _.,...__........
r .-
PERCOLATION PATE:
1.
2.
3.
Presoak Mark & time Drop Time Pate/11in. Inch
***CLASSIFICATIOIT:Suitable Provisionally Suitable Unsuitable
COFjq-,!E1,'TS :
SITE DIAGF.AM