419 Buck Seaford Rd �u
t q
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 (10NCAC pA . 934-1968) Permit Number
Name i^moi, -52-Zf.7'— i??c � 1 �'',� Date �'—�°- 'J�i'
Location
Subdivision Name Lot No. - Sec. or Block No.
Lot Size1/4, fir` House Mobile Home _ Business Speculation
No. Bedrooms No. Baths ( No. in Family _
Garbage Disposal YES El NO �'�
p Specifications for. System:
Auto Dish Washer YESNO E] ' ;, ' �•
Auto Wash Machine YES [tj NO ❑ � ,,
Type Water Supply /-7 __—
*This permit Void,if sewage system described below is not installed within 36 months from date of issue,
1
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.
i
lel
Certificate of Completion Date he,
*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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT �pR
Davie County Health Department �G��41E:
Environmental Health Section R
409 P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phoneys
1. Permit Requested By 70„ \/ W S% j l- Business Phone 11 9 - 7&17 "3�2 80
2. Address 2 3 ..1 Dem ,`s e- /, t, e `40;xs`6 n -Salem.ALI?
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventional-,/—'Other Type
Ground Absorption
c) Sub-Division Seq. Lot No.
5. System used to serve what type facility: House \/ Mobile Home Business
Industry Other
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms—Bath Rooms_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 3 urinals garbage disposal
lavatory 3 showers 3 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 /6 0 c K(:x
b) Land area designated to building site
c) Sewage Disposal Contractor nn//
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type?
This is to certify,that the information is correct to the best of my knowledge.
Marc,/_( 1 �f `I
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE.1 LOCAL LAWS
Allow 5 days for processing
sow
Directions to property: `
Qu �
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Date
s
Address 042, /na-+-off a,- Lot Size !G aet ,
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S
PS PS PS PS
U. U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) Zn?B> C�9 (Z�) PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils -ZR97 & PS
U U U U
4) Soil Depth (inches)
® ® PS
U U U U
5) Soil Drainage: Internal S S S S
PS
U U U U
External G9 �� S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space c= S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE —SUITA E PS—Provisionally Suitable
Recommendations/Comments:
Described by O' te a' Title b'-- Fes--• Date
SITE DIAGRAM
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3
Q ` L
d
a
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DCHD(8.82)
1 -
4.
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 Phone
1. Permit Requested By GE026 cy- EL/ZRBF77-f kimflU t-V Business Phone
2. Address 2.L12 MA61VOLIA AVC. MOCk.(yILLE Z7a2d-
3. Property Owner if Different than Above /Y)/_.f'. At ETNA /'/CHA2q 1
Address
4. Permit To: a) Install ✓ Alter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House ✓ Mobile Home Business
IndustryOther
b) Number of people 2
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions—f
Bed Rooms 3 Bath Rooms a�; 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 2- -3 urinals garbage disposal
lavatory 2-3 showers 2- washing machine
dishwasher I sinks `(' S
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? n o
What type?
This is to certify that the information is correct to the best of
my knowledge.
1?- l.2-8s
Date Owner Signature 6
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
l /S
Name 5� �Date �`
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS
U U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U U
External S S S
(b> PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S S
S PS PS PS
U 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 _T��!4.2 Date
SITE DIAGRAM
DCHD(6-82)