1140 Daniel RdJ f L? 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 -/ :P,f 3 % Date / rf^ 'gyp4293
Location C='./%`f_,S,r.�� �,,y /!!/� �. tom'-/� Z
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 ❑ NO pa Specifications for Sy
ste
Auto Dish Washer YES NO ❑ ,71
Auto Wash Machine YES g 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
10
Certificate of Completion 4r,-7 •y 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.
It
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT r�C C/
Davie County Health Department
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
1. Permit Requ,e� t,ed- ^By
2. Address �L�
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Z Alter Repair
b) Privy Conventional 'Other Type
Ground Absorption
Home Phone,=28 ` �
Business Phone
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homed Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions—1
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
lavatory
dishwasher
urinals
showers
sinks
garbage disposal
washing machine
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes'ef No
9. a) Property Dimensions 4% % 16,57 � 116
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 knowledge.
!L - � - FL /'�V' UA��
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
l� 6
o6ra.nclt &yi.
DCHD (6-82)
Address
FACTORS
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
ARFA 1 AREA 9
Date
Lot Size2211
AREA 3 ARFA d
Topography/ Landscape Position
U
U
S
PS
U
S
PS
U
'.) Soil Texture (12-36 in.) Sandy,
Loamy, Clayey, (note 2:1 Clay)P
6
-
S
PS
U
S
PS
U
I) Soil Structure (12-36 in.)
Clayey Soils
S
S
PS
U
S
PS
U
Soil Depth (inches)
p
S
PS
U
S
PS
U
Soil Drainage: Internal
S'
S
PS
U
S
PS
U
External
S
S
PS
U
S
PS
U
�) Restrictive Horizons
Available Space
S
EN
U
S
PS
U
S
PS
U
I) Other (Specify)
S
PS
U
S
PS
U
S
PS
U.
S
PS
U
1) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
DCHD (6-82)