230 Fulton Rd (2) ft
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 014c E A m c H Date3416
Z ��
Location7 �c�s� ��f 1 cn•. /� eZl� z!/. /� /1T �n� r =/C�i"G —
, 11r• _ f,I/
Subdivision Name Lot No. Sec. or Block No.
Lot Size /y House Mobile Home _ ✓ Business Speculation
No. Bedrooms --� No. Baths Z No. in Family _
Garbage Disposal YES ❑ NO ❑
Specifications for System: /000
Auto Dish Washer YES p NO ❑ otOD
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.
/2 c:wc,rz
V �1
Improvements permit by_--,
*Contact a representative sof he 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
Certi tate of Completion Date
*The signing of this certificate shall in ►ca a that the system describe above has been installed in compliance with
the standards set forth in the atove gulation, but shall in NO way be taken as a guarantee that the system will function
satisfactcidly_foLzay-givertpenod of time.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name f�L '�� Date 7-
Address
Address , '
�— Lot Size
Art'7 77-ac-
FACTORS
7-eGFACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SPS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) a -(M PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils M -&P PS PS
U U U U
4) Soil Depth (inches) S S S
® PS PS
U U U U
5) Soil Drainage: Internal S S
__ P PS PS
U U U
ExternalS S
(t) PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S
S PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification PS PS
'—
U—UNSUITABLE S—SUITABLE P —Provisionally Suitable
Recommendations/Comments:
Described by Title �` Date/��L �3
SITE DIAGRAM
DCH (6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �3
Davie County Health Department y
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone $q«
/
1. Permit Requested By t -b 6c- lam( Business Phone
2. Address 01 0c.06'r Ce.. " N C_ CP o O'Co
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter RepairJ�
b) Privy Conventional! Other Type.
Ground Absorption
c) Sub-Division Sec. Lot No
5. System used to serve what type facility: House Mobile Home Bs
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Bath Rooms a Den w/Closet 1
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 a urinals garbage disposal
lavatory a showers a washing machine
dishwasher sinks
8. a) Type water supply: Public ✓ Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions -
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? 10 0
What type?
This is to certify that the information is correct to the best of my knowledge.
063 - ,
Date Owner Sig re
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property: R 0010
DCHD(8-82)