P3592 Williams 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
Name �1r`%�,r°, 2r.� Date - 4�✓� ''�''3'591
Location
r ? F
Subdivision Name
Lot No
Sec. or Block No. _
Lot Size" House Mobile Home —f �'y Business Speculation
No. Bedrooms No. Baths —_ No. in Family
Garbage Disposal YES ❑ NO ❑ Specifications for System:
Auto Dish Washer YES ❑ NO ❑ �^`' �`'�-"
Auto Wash Machine YES ❑ NO -❑
Type Water Supply _
*This permit Void if sewage system described below is not, installed within 36 months 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..;
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.
• k 1
APPLICATION FOR SITE EVALUATION /IMPROVEMENTS PERMIt- 34,Y�l.
Davie County Health Department
Environmental Health Section Ad
P. 0. Ekjx 665
Mocksville, N.C. 27028
CONSTRUCTION SFIALL NOT BEGIN UNTIL IKIPROVEMENTS PERMIT HAS 8&E.N IFBttfi:t),
Nome
1. Permit Fteque ®!► Business Phone
2 Address
S. Property Owner n Different than Above
_ Address
4. Permit To: 8) Install.— After Repair
b) Privy Conventional Other Type ---
Ground Absorption �l6
c) Sub-Divisionpe .9 Sec Lot No.
5. System used to serve what tyfacility: House—_ Mobile H�arne_._. EIusineos.__.
Indust'•y_.__. Other.
b) Number of people_______. _.
6. a) 0 hot,se or mobile home, state size cif home and number of rooms.
House Dimensions l 2 ( d
Bed Rooms Bath Rooms... _ — Den w/Closet ..
b) If Business, Industry or Othar, State: Number of persons wrved
What type business, etc.
Estimate amoudof waste daily (24 hours)-----
7.
ours).___ _
7. Number anct type of wfor-using IIxtures:
cotnmo6s�T urinals_-.- __ garbage disposal
lavatory / showers wasHng machine
dishwasber sinks
& ; a) "Type water supply. Public_-- Flrivaje._ ►� Community
b) Has°the water supply system been approved? Yes__ No -----
9.
o_'!9. a) Property Dimensions .?�� ------ -
b) Land area designated to building -,-
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewalje system is Intended to serve?
What type?
This Is to cortify that the information ' rrect to the best of my knowledge.
Date _ Owner Signatur �J D
OWNER IS SOLELY RESPONSIBLE FOR COMPUA. -E WITH ALL STATE AN LEOCAL LAWS
Allow 6 days for processing
Directions to property. i
f
C"P•Q
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size��
FAr:Tr)RQ AREA 1 AREA 2 AREA 3 AREA 4
Topography/ Landscape Position
S
S
S
OUPS
PS
PS
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
PS
PS
PS
U
U
U
U
I) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
j
PS
PS
PS
,
U
U
U
�) Soil Depth (inches)
S
S
S
S
PS
PS
PS
U
U
U
U
Soil Drainage: Internal
S
S
S
S
PS
PS
PS
U
U
U
External
S
S
S
S
PS
PS.
PS
U
U
U
1) Restrictive Horizons
------
Available
Available Space
S
S.
S
S
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
PS'
S
PS
S
PS
S
PS
U
U
U
U
74?
i) Site Classification
,
U—UNSUITABLE
Recommendations/ Comments:
Described by
SITE DIAGRAM
DCHD (6-82)
S—SUITABLE PS—Provisionally Suitable
Title Date