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` 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 C) \ N Date 2 N2 rJ U
n �
Location �'C
Subdivisibn Name Lot No. Sec. or.Block No.
Lot Size (7> k- House Mobile Home ' Business Speculation
No. Bedrooms No. Baths No. in Family y
Garbage Disposal YES 0 NO 2" Specifications for System:
Auto Dish Washer aYES ❑ `NO ����
Auto Wash Machine ' YES E NO ❑
Type Water Supply a d cJ �( 3► �;
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
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6 F411
p,
Improvements permit byC 1','--,
'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
tl'V t
f
Certificate of Completion `\a'a Date J b - y x S
"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 betaken as a guarantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department `�� AUS 3
Environmental Health Section RECEt
R 0. Box 665
Mocksville, N.C. 27028 a
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone C0.$- 1-\(01 q
1. Permit Requested By o-.moo- o t15 Business Phone S Ac�c�e
2.":Address cel-1C>oZ�
3. Property Owner if Different than Above �s cs� on, F 3 a�-,Q 16 nc3.
Address e-
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 Homes
IndustryOther
b) Number of people 7
6. ay If house or mobile home, state size of home and number of rooms.
House Dimensions 7clit XI yX
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 a urinals garbage disposal
lavatory showers washing machine
dishwasher _43 sinks I
8. a) Type water supply: Public ✓ Private Co�rmunity
b) Has the water supply system been approved? Yes � No
9. a) Property Dimensions I &,rL ! 11-42- aQ.P-C S
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? `nC1%
What type?
This is to certify that the information is correct to the best of my knowledge.
YXY)
Dat Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name— Date
Address Lot Sizes-�
FACTORS AREA1 AC2\ AR9Zb ARE
1) Topography/Landscape Position S C�
U U
2) Soil Texture (12-36 in.) Sandy, P
Loamy, Clayey, (note 2:1 Clay) P
U U
3) Soil Structure (12-36 in.) ?'Sp
Clayey Soils lT ��SS3
(� U U
4) Soil Depth (inches) P PS - PS
U
5) Soil Drainage: Internal
U U U
External
PS
U U U
6) Restrictive Horizons
7) Available Space AS>
P
U
U U
8) Other (Specify) S S S S
PS PS PS PS
9) Site Classification
U—UNSUITABLE
(�p S—SUIT PS—Provisionally Suitable
Recommendations/Comments:
Described by �` Title ' �=�--�'� Date �-
SITE DIAGRAM
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DCHD(6-82)