P5108 Buckingham Ln H t
DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance with O.S. of North Carolina Chapter 130 Article 13c
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name ,� - Date r";qtr d
Location
\, ` ,•:� t3�r`l-cam w r`a �
Subdivision(Weq Lot No. Sec. or Block No.
Lot Size : House Mobile Home _f'/ Business Speculation
No. Bedrooms No. Baths 1 No. in Family ? _
Garbage Disposal YES ❑ NO Specifications for System:
Auto Dish Washer YES ❑ NO
Auto Wash Machine YES r NO ❑ 1
Type Water Supply _
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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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 ��*�
Certificate of Completiont 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.
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� APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County"Health Department
Environmental Health Section CCQ
P. O. Box 665 11 SD
Mocksville, N.C. 27028 R
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 15 I
1. Permit Reques d ByPA& Business Phone
2. Address 2 6
3. Property Owner if Different than Above
Address
4. Permit To: a) Install-ZAlter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile HomeyBusiness
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home/and number+of rooms.
House Dimensions lo 'X WS di Q e d room
Bed Rooms Bath Rooms Den w/Closet
b) If Business, Industry or Other, State: Number of persons served
What type business, etc. I-i I/-e, ,a y
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes urinals garbage disposal
lavatory showers washing machine
dishwasher sinks
8. a) Type water supply: Public Private Community t/
b) Has the water supply system been approved? Yes- No `
9. a) Property Dimensions O aefT
b) Land area designated to building site �— d
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? n d
What type?
This is to certify that the information is correct to the best of my knowledge.
3
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)
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name_. ��- � t'�-� -- Date
Address Lot Size 1"Q
FACTORS AR(�ON AR6Z2) AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS S� PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey SoilspS
is�
PS PS
U U
4) Soil Depth (inches) S S S S
PS ;0 PS PS
U U U
5) Soil Drainage: Internal S S
PS PS PS PS
U U
External S S
PS `YS PS PS
U U U
6) Restrictive Horizons 1
7) Available Space S S S S
PS <I!S:) PS PS
U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
9) Site Classification S
U—UNSUITABLE S— rmstE PS—Provisionally Suitable
Recommendations/Comments:
Described by IL� � Title Date `g �S
SITE DIAGRAM
DCHD(6-82)