238 Ollie Harkey Rd (2)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
Name Date _��i`o �— t?`: . i284
Location �T/%ate' r = rte^' T/�� l�f�T'"�� •'T_G_Ti_-rf_sr'sS%�--=-T��
Subdivision Name Lot No. Sec. or Block No.
Lot Size L House Mobile Home _rte Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YES ❑ NO
Specifications for System:
Auto Dish Washer YES NO ❑ �1-11 A IYSZ1 �;
Auto Wash Machine YES NO ❑ c�,Y
Type Water Supply Z1'!_l
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Olt -
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: 704-633�4,,-5985.
Final Installation Diagram: System Installed by
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.
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT ti Q.
Davie County Health Department 1� .�
Environmental Health Section
P. O. Box 665 111
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requested By
2. Address L;ZLe � 0
3. Property Owner if Different than Above
--.--:Address
4. Permit To: a) Installer Alter Repair
b) Privy ✓ Conventional Other Type
Ground Absorption
Home Phone 634-3-773
Business Phone
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile HomeLG Business
IndustryOther
b) Number of people /
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions !a x (y5
Bed Rooms A 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 1 urinals
garbage disposal
lavatoryshowers washing machine 1
dishwasher sinks
8. a) Type water supply: Public Privateer Community
b) Has the water supply system been approved? Yes No -
9.
o 9. a) Property Dimensions A -►��
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? A10
What type?
This is to certify that the information is correct to the best of my knowledge.
Date dKner Signatu)
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
Al 61L7J_ 6 0
DCHD (6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �"Date Jr`4 '
Address Lot Size
FAr.TnRC AREA I AREA 9 AREA '1 ARFA A
Topography/ Landscape Position
9)
S
S
S
',
U
S
PS
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
(j
PS
�'
U
PS
U
1) Soil Structure (12-36 in.)
Clayey Soils
S
PS
S
PS
S
�
S
PS
0Qj
<a
U
U
i) Soil Depth (inches)
S
S
S
PS
�
PS
Q
P
U
PS
U
) Soil Drainage: Internal
S
S
S
PS
�
(2�
U
PS
U
External
��
S
PS
U
U
U
U
i) Restrictive Horizons
I ,( ttt—
d1-- j—
�
Available Space
QM
PS
U
U
U
U
1) Other (Specify)
S
PS
S
PS
S
PS
S
PS
U
U
U
U
Site Classification
QS
L1
PS
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments: S6w S. z.- � 3 h.l,
n C�,.. S- � 43
Described by •'mew-� Title � - Date
SITE DIAGRAM
DCHD (6-82)