121 Gawain Way DAVIE COUNTY HEALTH DEPARTMENT
`f 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 1 O .1934-.1968) Permit Number
Name 't a ��
Locationyr
G�
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home 1- Business __ Speculation
No. Bedrooms � — No. Baths No. in Family _
Garbage Disposal YES ❑ NO p'' Specifications for System:
Auto Dish Washer YES NO ❑
Auto Wash Machine YES j NO ❑ i
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
r ,
• I
1
Improvements permit
*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 Compltion 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, buj shall in NO wa�be taken as a guarantee that the system will function
satisfactorily for any given period of time./ J/
RECEIVED Ni"tr 2 2
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 9 9 g_ I?83 G
1. Permit Requested By JQrr1E'-5 L . /S%c hg r Q/s'oh Business Phone
2. Address 007L&- -;'W oc l<s "".Ile , /t/, C' ,
3. Property Owner if Different than Above Ale J4, %Sn.•e a r a/c o it
Address . 3-6,1177 721cc/CS�%�/.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 Home V"Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /Y X 70
Bed Rooms a Bath Rooms /�l2 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 urinals garbage disposal
lavatory showers / washing machine /
dishwasher sinks /
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes "-No-
9.
—No9. 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?
What type?
This is to certify that the information is correct to the best of my knowledge.
Date 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. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name James E. Richardson Date
Address Rt. 2, Box 197 Lot Size 1 – 2 acres
Mocksville, NC 27128
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S 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) PS PS PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U U
4) Soil Depth (inches) S S S S
PS PS PS PS
U U U U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S 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 S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Hall Title Sanitarian Date
SITE DIAGRAM
DCHD t6 82) ��,,