191 Jones Rd DAVIE .1317 7,
�;• ;.��-r:•- -: COUNTY HEALTH .DEPARTMENT , • • .
IMPROVEMENTS PERMIT AND CERTIFICATE OF. COMPLETION
"NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article.l3c ' r-� -:
Sewage Treatment and Disposal Rules (10 NCAC 10A,1934-.1968) , rer` m� it Nuber
NameDate '" • , .,
Location
Subdivision,N_.prh,e�p� Lot No. Sec. or Block No.
Lot Size House ' Mobile Home _ Business Speculation
No. Bedrooms
Baths rte: No: 'in Family
Garbage Disposal -YES ° NO .f�
e, I V r", Specifications for' System:
Auto Dish Washer; YES V NO °
di
Auto Wash Machine = YES NO .11 C J Ir
Type Water Supply Q ;;
`This permit Void if sewage system described below isnot installed within 36 months from date of issue.
. -
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L
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 1:004:30 P. on dray.of;completion. Telephone Number: 704-634-5985.
Final Installation Diagram: " System Installed by,
• ���- ,pj 'lir .�� ? - � .
Certificate' f Completion - o.
- oDate
-P : -
#The signing of:this certificate shall indicate that the system.described above has been'installed.in. compliance:wlth
-the standards set forth in the above'regulation, but shall in NO way.be,taken.as a guarantee hat the'system"will function,; .
satisfactorily for any given period of time,
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ..
Davie County Health Department t� �
Environmental Health Section G \`�
R 0. Box 665 ��►
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.7 5!/
Home Phone 63/�` 1J 0
1. Permit Req ues ed By ��� c.�— 0 S c Business Phone .6-3=
2. Address / -2-70
3. Property Owner if Different than Above e
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: Housed Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions &asi-: k .SCS --c-'f—
Bed Rooms----5'
oom Bath Rooms Den w/Closet_
b) If Business, Industry or Other, State: Number of persons served 14��
What type business, etc.
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
b) Has the water supply system been approved? Yes No 9
9. a) Property Dimensions Z5:�&`(�K k Ao 3 -6 F X' :3,2 .G 1 0 S/3
b) Land area designated to building sem
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? WO
What type?
This is to certify that the information is correct to the best of my knowledge.
4- 6 -2 7 ;
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
cad t n1
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION I
Name C� 9— Date
Address Lot Size
FACTORS EA 1 AR AREA 3 AREA 4
1) Topography/Landscape Position S S
PS's PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S `S S S
Loamy, Clayey, (note 2:1 Clay) kzff> PS PS
U U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
r U U U U
4) Soil Depth (inches) S S S
PS PS PS PS
U U U U
5) Soil Drainage: Interhal SS
pS P PS PS
U U U
External S S S
p� PS PS PS
U U U U
6) Restrictive Horizons —'�—
7) Available Space SS S
PS PS
U U U
8) Other (Specify) S S S
g PS PS
7�
U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE PS—P ovisionaliy Suitable
Recommendations/Comments:
Described by Title Date y�
SITE DIAGRAM
DCHD(682)