P3480 Hwy 158DAVIE 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
Location J -i
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
[I NO E]-
Auto Dish Washer
YES
E] NO E]
Specifications for System: c".:
Auto Wash Machine
YES
Ej NO E]0
Type Water Supply
4,
10
*This permit Void if sewage system described below is not installed with in,,.36- rm(5ht-hs from date of issue
Improvements permit by
*Contact a representative of the Davie County Health Department for fii )0 2 on of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Num -634-5985.
Final Installation Diagram: S tem Instal y
Certificate of Completion Date
*The signing of this certificate shall indicate that the system described above has been installed in compliance ith
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.
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
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 YES :❑ NO Q Specifications for System: 2',C..
Auto Dish Washer YES Ej NO ❑
Auto Wash Machine YES E] NO ❑
Type Water Supply
*This permit Void if sewage system described below is not installed
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 Numbe':7b4-634-5985.
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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name -M�%� L7�4jf'� Date 3' 1 �' X -y"
Address �_` 1�/Sy2 Lot Size
E
I
E
Topography/ Landscape Position
SS
S
S
65>
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
S
Loamy, Clayey, (note 2:1 Clay)
P
PS
PS
PS
U
U
U
t) Soil Structure (12-36 in.)
S
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
g Soil Depth (inches)
S
S
S
S
p
PS
PS
PS
U
U
U
Soil Drainage: Internal
S
S
S
S
PS
PS
PS
PS
U
U
U
U
External
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Restrictive Horizons
Available Space
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Other (Specify)
S
S
S
S
PS
PS
PS
PS
U
U
U
U
1) Site Classification
U—UNSUITABLE---'
Recommendations /Comments:
Described by ma
SITE DIAGRAM
DCHD (6-8 )
S—SUITABLE PS—Provisionally Suitable
Title
Ta ,f✓/c. 7s 1J/FT�r�cra-
Date 3 %2 ^41
S-'� _ry
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
1. Permit F
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install V Alter— Repair
b) Privy_ Conventionals Other Type
Ground Absorption
c) Sub -Division Secy Lot No.
5. System used to serve what type facility: House— M✓ obile Home— Business
Industry— Other_
b) Number of people
6. a) If house or mobile home, state size of home and number of ropms.
House Di""A s` X ����L
Bed Rooms Bath Rooms Den /Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc.
Estimate amount of waste daily (24 1
7. Number and type of water -using fixtures:
commodes
lavatory
dishwasher —
8. a) Type water supply:
showers
sinks 1
Public Private Communi
b) Has the water supply system been approved? Yes— No
9. a) Property
b) Land area designated to building site
c) Sewage Disposal Contractor
Phone o/7''? /)
ss Phone 6 3 V' C2/
3
garbage disposal
washing machine /
10. Do you anticipate any additions or expansionsof the facility this sewage system is intended ton serve? e-5
What type? Aad 0'W0' VAlh ru (" . � '- 1Q�j i `�' zln - 2 0_";
This is to certify
/that the information is correct to the best of my knowledge.
Date Owl a Signat
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH AL rSTATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6-82)
F