170 Candi LnILI
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF, COMPLETION
Issued
fl I; k fl- 0 ; N 11 f,
IN1:
NOTE. [--: OSUIZ; " V111P Cl"IU wit . . V UIL C;LIU "CL k-l"CIPLer 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934,1968) Permit Number
Name
Date364
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 [D-/ Specifications for .,Syster
p:
Auto Dish Washer YES NO
Auto Wash Machine YES NO -E]
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 rqonths 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 (J\JA
00
0\
10
Certificate of CompletioDate?
*The signing of this certificate shall indicate that the system des4'6
crritd above has been installed in complia , nce.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.
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 [D-/ Specifications for .,Syster
p:
Auto Dish Washer YES NO
Auto Wash Machine YES NO -E]
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 rqonths 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 (J\JA
00
0\
10
Certificate of CompletioDate?
*The signing of this certificate shall indicate that the system des4'6
crritd above has been installed in complia , nce.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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section _
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address
3. Property Owner if Dif
Address
/.7 Lt. :? I C' 9
4. Permit To: a) Install Alter Repair
b) Privy L_; 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
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions � 0 X l.�_
Bed Rooms— 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 urinals
G
lavatory showers
dishwasher sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes t/ No
9. a) Property Dimensions
b) Land area designated to building site
c) Sewage Disposal Contractor
garbage disposal
washing machine
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.
r
7
Date wner 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
FAr.TORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date``
Lot Size
AREA 3 AREA 4
5)
6)
8)
ARFA 1 AREA 2
1) Topography/ Landscape Position S �S �-, S S
PS PS
`--� U U U
�) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PC S� PS PS
U U
;) Soil Structure (12-36 in.) S S S�
Clayey Soils C /% PS PS
U U U U
4) Soil Depth (inches) ® S S
PS PS
U U U U
Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S S
PS PS PS PS
U U U U
Restrictive Horizons
Available Space S S
PS S PS PS
U U U U
Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification i?Kl—
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title ��✓ Date
U—UNSUITABLE
Recommendations/Comments:
Described by _
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title ��✓ Date