P3673 Wood ValleyDAVIE 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 S' --r+L 0 Date 7-- r
62 3073
Location k j
Subdivision Name. Va-fle-Q, Lot No. Sec. or Block No.
Lot Size le'l, House Mobile Home Business - Speculation
No. Bedrooms No. Baths No. in Family '7/
Garbage Disposal YES E] NO Specifications for System: 1 ri,� L :, I
Auto Dish Washer YES E] NO g -
Auto Wash Machine YES g- NO -E]
Type Water Supply 0;r,, 4
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
Improvements permit b y
*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:
, =0I OjYA
1,ryA
System Installed by Alo-
Certificate of Completion Date
'The signing of this certificate shall indicate that the system describeiiabove 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.
#-T 6
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
Lot Size
FAr.TOPR APFA 1 APFA 9 ARFAS ARFA A
5
6
8
8
1) Topography/ Landscape Position
1E5!:>
-Zff:>
S
S
PS
PS
PS
PS
U
U
U
U
2) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
<!::;�
PS
PS
U
U
U
U
Soil Structure (12-36 in.)
S
S
S
S
Clayey Solis
<:!0�:>
<Z1M=:-
PS
PS
U
U
U
U
Soil Depth (inches)
S
S
S
S
<2�
<==as=-
PS
PS
U
U
U
U
Soil Drainage: Internal
S
S
S
S
<fn-->
<:�
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
U
U
U
U
Restrictive Horizons
Available Space
S
S.
S
S
<2�
<Tn:�
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 S—SUITABLE PS—Provisionally Suitable
Recommendations/ Comments:
Described by Title Date to).-e'l
SITE DIAGRAM
'41
DCHD (6-82)
APPLICATION FOR SITE EVALUAV ION MPROVEM ENTS PERMI"t
Davie County Health Dtpaitmelit
Environmental Health Section
P. 0. Ek)x 605
MMI(svills. N.C. 27023
CONSTRUCTION SHALL NOTBEGIN UNTIL IMPROVEMENTS PERMIT HAS GVFN lawfil).
140me Pope 4_1
1. PWmh Rip"ted
2.- Address
& Property Owner If Dwsent du bove
4, Porn* To: a) Install.— Alter— Repair—
b) Privy— Conventional_ Other Type—
Ground Absorption
c) Sub-Divislon— Sec.— Lot No.
5. SyMm used to serve what type facility: House— Mobile Home_E::f� Elusine4s_
Industry-- Mer__
b) Number of people___�_
6. a) 11 h0L88 or mobile home, state size of home and number of rooms.
House Dimensions 2-4 x 2�
Bed Rooms Bath Rooms..--Z:f'- Den w/Closet-
b) If Business, Industry or Other, State: Number of persons served
What -type business, etc.
Eitimate'Amounfof wage daily (24 hours) ---__.-
7. NuMbei an4 type of to using fixtures:
commAes- Wr urinals---- — garbap cPaposal
lavatory Z— showers — washing m.achine—
dishwasber sinks
8. a) Type water supply: Public- F1rivaje___ Community—
b) Has the water supply systern been a pproved? Yes -=!f No
9. a) Prop" Dlm*nslons_j-��..,
b) Land area designated to bulk
c) Sewage Disposal Contractor
10. Do you anIcipate any additions
What type?
This Is to cortity that the information is*corr ct to the best f y knowledge..
Date Owner Signature
OWNER IS SOLELY RESPON.311BLE FOR COMPLIAIN-�E WITH ALL STATE AND LOCAL LAWS
Allow 5 days fDr processing
Directions to property.
C CHD to -02)