P3529 William Fred Allen- .. . • .- .. _. .... ..- v.. .. .- -. ... .w .. a .. �'. l: -1.. .a � a - -. • .. - _ .t.
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 !. 2; Z
Date �si"
3529
Location sme�
Subdivision Name
Lot No. Sec. or Block No.
Lot Size House
Mobile Home _±:: -- Business Speculation
No. Bedrooms No. Baths %
No. in Family t;�Z__
Garbage Disposal YES ❑ NO ❑
Specifications for rSystem:
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 lr
'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.
Address
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date'
Lot Size
FAr.TnRS AREA 1 AREA 2 AREA 3 ARFA A
Topography/ Landscape Position
S
S
S
(AP
PS
PS
PS
U
U
U
U
!) Soil Texture (12-36 in.) Sandy,
S
S
S
Loamy, Clayey, (note 2:1 Clay)
AU
PS
PS
PS
U
U
U
1) Soil Structure (12-36 in.)
S
S
S
Clayey Soils
PS
PS
PS
U
U
U
U
�) Soil Depth (inches)
S
S
S
S
PS
PS
PS
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
�) Restrictive Horizons
Available Space
S
S.
S
S
PS
PS
PS
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:
S—SUITABLE PS Provisionally Suitable
Described by Titled Date l�
SITE DIAGRAM
DCHD (6-82)
APPLICATION FOR SITE EVALUATION/ IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Req sted By �� Business Phone 11736,� "
2. Address ..Q 6 Y.
3. Property Owner if Different than Above
Address
4. Permit To: a) Install '-� Alter Repair
b) Privy Conventional her Type
Ground Absorption
c) Sub -Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home�siness
IndustryOther
b) Number of people
6. a) If house or mobile home, sta size of home and number of rooms.
House DimensionsJ=?i����
Bed Rooms— Bath Rooms Den 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
urinals garbage disposal
showers
dishwasher s. s
8. a) Type water supply: Public Private Coy�mmunftb) Has the water supply system been approved? YesNo
9. a) Property Dimensions
washing machine
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 ce ify that the in is correct to the best
/of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD (6.82)
STATEMENT
DAVIE COUNTY HEALTH DEPARTMENT
ENVIRONMENTAL HEALTH SECTION
210 HOSPITAL STREET
P. 0. BOX 665
MOCKSVILLE, NORTH CAROLINA 27028
(704) 634-5985
DATE
DETACH AND MAIL WITH YOUR CHECK. YOUR CANCELLED CHECK IS YOUR RECEIPT.