P3748 Milling 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
�—
Date Name_ �-"3 ( a 37448 'y
r�
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size i :f House Mobile Home _ "� Business Speculation
No. Bedrooms c- No. Baths _�_ No. in Family4 _
Garbage Disposal YES :❑ NO D Specifications for System:
Auto Dish Washer YES ❑ NO :p
Auto Wash Machine YES [Er- NO C]
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit by`` -
ii
*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: ST "k StO--
C�..
System Installed by
�i 1p W Cwk C>s , otu- QnSs: W. L: h afJ4�.
Certificate of Completion 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.
DAVIE COUNTY HEALTH DEPARTMENT
_ .:...AMPROVEMENTS 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 ��:, , =,� '/. �1,, Date �� - / 3 - '�{� '•' �,� �Y
K Location
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 E)NO g Specifications for System:
Auto Dish Washer YES ❑ NO J2
Auto Wash Machine YES p'" NO ❑
Type Water Supply _—
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
r
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: c�a-i. n,.} SPS. _ System Installed by VIQ"'r�
�Ch F l� c'�i' ,• ^^...'..i CC"iw ',)S 01 W4_- T % �u LV. r7.
�E j
L: � � 6 _ �••
P t 8(`W+li, �o �c (�ftt.x-�3C tS\ PR Biu. 2' 1 S- r �' f'''•
Certificate of Completion 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.
ld -aqr
t
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
1. Permit F
2. Address
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
r.
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair,
b) Privy Conventional Other Type
Ground Absorption
Home Phone�Q� d%
Business Phone609 9 "«a -
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House 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 -190 90 x Ste_ --
Bed Rooms— Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
7
What type business, etc.
Estimate amount of waste daily (24 hours)
Number and type of water -using fixtures:
commodes urinals
lavatory
dishwasher
showers
sinks
8. a) Type water supply: Public/Z Private Community
b) Has the water supply system been approved? sem. No,��
9. a) Property Dimensions I t
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?
garbage disposal
washing machine
What type?
This is to certify that the information is correct to the best of y knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
F, i
DCHD (6-82)
Name—
Address
s
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
✓dfli?S w
Date
Lot Size
GerITnPQ AREA 1 ARFA 9 AREAS AREA 4
Topography/ Landscape Position
SS
d!S—
C:b
PS
S
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
P
PS
PS
U
U
U
U
i) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
P
PS
PS
PS
U
U
U
U
Soil Depth (inches)
S
S
S
S
P
PS
PS
U
U
Soil Drainage: Internalt
S
S
PS
PS
PS
U
U
U
External
_fS
S
S
S
S
PS
PS
PS
U
U
U
i) Restrictive Horizons
') Available Space
S
PS
S
PS
S
PS
S
PS
U
U
U
U
S) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE
Recommendations/Comments:
S—SUITABLE PS—Provisionally Suitable
Described by n,�'.^-Y� Title k� /c�� Date
SITE DIAGRAM
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vv
N
DCHD (6-82)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 13 19 20 2 1 22 23 24 25 26 27 2329 30 31 32 33 34 35 36 .37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
2
3
5
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