169 Feed Mill Rd • * Ir DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION,,:Z.,
'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 WILLIAr.� P� Y01t- Datei—G _ Z.? L7r 1.1 1-1�:,�., 33;ry
Location So u✓it evc c "7'v a/V /f is ryF t)c p +'h i c L (.0T ln–
F 'all rt"VF y fit, /-r. P,
Subdivision Name Lot No. Sec. or Block No.
Lot Size X 30o House `'� Mobile Home — Business Speculation
No. Bedrooms _ No. Baths Z No. in Family _
Garbage Disposal YES E NO
Specifications for System:/DOD
Auto Dish Washer YESNO p "
Auto Wash Machine YES � NO � J'°�D X 3 X y7 S70,14
Type Water Supply "> g ' a^ &ir-ur C1 f
`This permit Void if sewage system described below is not installed within 36 months from date of issue.
s`JSTf rv\ MUST 0z Kc t""
St(ALLuLu 12 CcVEZ Q '
Improvements permit byf43
*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
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Certificate of Completion Date
"The signing of this certificate shall indicate that the system describe 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. 0. Box 665_._._. ....._.._......_.........
_ Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name W IU-/A r-k � OfL Date
Address 9-T 3 Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position SS S S
PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) (I!D CLT.53) PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils M�) 4rs) PS PS
U U U U
4) Soil Depth (inches)
® dIP PS PS
U U U U
5) Soil Drainage: Internal ® S S S
PS PS
U U U U
External (h (29:) S S
PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by ''� Title - Date�'6
SITE DIAGRAM x
P
G
DCHD(6-82)
a APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
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.
Home Phone
1. Permit Requ ted By i i4/'1? ok Business Phone 70u'63G—�QD6
29g
2. Address 31 LEICe.NC 7-7000
3. Property Owner if Different than Above �—
Address '—'�-
4. Permit To: a) Install ✓Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-DivisionSea Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people Z-
6. a) If house or mobile home, state size of home aDd number of rooms.
House Dimensions IZ/7 S • (11-1'ygo ��f)
Bed Rooms 7 Bath Rooms 2— Den w/Closet l
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 2— urinals garbage disposal
lavatory. Z showers Z` washing machine
dishwasher ,r� sinks ! moble
8. a Type water sup - PR✓ Private Community
yp pp v Public y
b) Has the water supply system been approved? Yes NoX_
9. a) Property Dimensions //Z X 30y
b) Land area designated to building site &2-X�7Od
c) Sewage Disposal Contractor _�'. eof vafz eQ
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? /lt>
What type?
This is to certify that the information is correct to the best f my k wledge.
Date Owner ignature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)