648 Mr Henry Rd° 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 and Disposal Rules (10 NCAC 10A .1934'.1968)
Permit
Number
Date
U
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 YESF-1NO
Specifications for System:
Auto Dish Washer YES [] NO
Auto Wash Machine YES E] NO ��
�r
Type Water Supply
.,
*This permit Void if sewage system described below is not installed within 36 months from date of issue
'
_
/
� \
' \
`
`
/ \ `
Improvements permit by�--L I-
ounty)H
*Contact a representative of the Da, I C alth Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on da of comp etion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by
/
/
Certificate ofCompletion 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.
- L1' cra
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.
Home Phone 7 % 0
1. Permit Requested By 9Business Phone S ��
2. Address
3. Property Owner if Different than Abov _
Address
4. Permit To: a) Install,4Z Alter epair.
b) Privy Conventional Other Type
Ground Absorption
c) Sub -Division Sec. Lot N
5. System used to serve what type facility: House Mobile Home Business
Industry Other
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 4____
lavatory
dishwasher
urinals
showers
sinks
garbage disposal
washing machine
8. a) Type water supply: Public Private_j,___G"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
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 kno I dge.
Date wner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
(4Uj 9,L w
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name c� ���\�\c Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA d
1) Topography/ Landscape Position
PS
S
�
S
�
S
P
g
U
U
U
2) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)
S
(2b
&
PS
U
U
U
3) Soil Structure (12-36 in.)
Clayey Soils
, S
PS
S
PS
S
�S l
�J
U
U
U
1) Soil Depth (inches)
S
S
S
<M
S
U
U
i) Soil Drainage: Internal
S
P
U
PS
PS
External
&
P
�
(1
U
U
U
U
i) Restrictive Horizons
Available Space
S
Q
S
–Cl
S
PS
U
PS
I) Other (Specify)
S
PS
S
PS
S
PS
S
- S
U
1) Site Classification
V�(�D-"�
S
S
5 q'
R -S
U—UNSUITABLE S—SS nWBLE' PS—ally Suitable
Recommendations/ Comments:
Described by i� Title Date,/. --3,5 -<Zo
SITE DIAGRAM
DCHD (6"82)