118 Kelly Ave lip. -- - r•"`�"+'^'ia-,:s-r ''v -. w -,�� -, - -` t ..-•.. .i. •u...".<' �. .a vl�'^�w �--- -�- ,. ry
DAVIE• COUNTY HEALTH' DEPARTMENT,
IMPROVEMENTS PERMIT AND. CERTIFICATE OF COMPLETION
*NOTE Issued in Compliance with G.S. of Noift Carolina-Chapter 130 Article 13c
Sewage Treatment and, Disposal Rules (10 NCAC'10A 1934-.1968) Permit Number
e
Name /&/,/,J� �G 596
Location -
-.Subdivision'Name I� Lot No. Sec. or Block No.
Lot Size. House
_ _.Mobile Home — r Business _— Speculation ,
No. Bedrooms .No: Baths _s No..in Family
Garbage Disposal YES,-E] NO Gy= I Specifications for System:
Auto Dish Washer - YES NO
Auto Wash Machine YES NO Q'' •
TYRe Water Supply - - � 4_1? � a
i;
' - Ili • �., ,, • ' --•�• �� '� tom••,
"This permit Void if sewage-syst m described below is not installed within 36 months from date of issue.
• I) �'.� .. Sir+•-..- ..'^""_-'.,._.•.r+_� -
' Improvements permit by
' :•,. • . • 11 - —= r -- -
*Gontact arepresentative 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 DiagramF" System Installed by a a
F Certificate of Completion � 9 Date '� SSS
#The signing of-this certificate shall indicate that A 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 functiori
satisfactorily for any'given'period of,time. `i;
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
R O. Box 665 RECEIVED DEC 0 7 S87
Mocksville, N.C. 27028
-CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home PhonelP•�/y
1. Permit Requested By o �✓ � "� � �� Business Phone �3�_-✓���/
2. Address wi°_ �«�- -C•
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 Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
` Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions .21.e f2-
Bed Rooms Bath Rooms O�2- Den w/Closet /
b) If Business, Industry or Other, State: Number of persons served
What type business, etc. _r
Estimate amount of waste daily (24 hours)
7. Number and type of water-using fixtures:
commodes • urinals garbage disposal
lavatory showers Z washing machine
dishwasher / sinks 2-
8.
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes � No
9. a) Property Dimensions—-- ! /7 4&rLa s
b) Land area designated to building site A `'ety_
C) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? /yC�
This is to certify that the information is correct to the best of m knowledge.
_7/6e7 '4�4 -/Z;
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
IPP
044 w
DCHD(6-82) �►�p
J
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name �2 �/ Date 3f��
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
pS PS PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS PS
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: . y
Described by ��LTitle �,, h Date
SITE DIAGRAM
P
UCHD(6.82)