330 Hilton Rd '= 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 �' .:, . `r'; . .G' ,, . Date f :j,-' %.c, 0 3539
Location `Z" , 10✓ 1�`,� ,� f_., '. r, ✓% <-,r" �,/; �✓�:,
Subdivision Name Lot No. Sec. or Block No. r
Lot Size c House Mobile Home / Business Speculation-
No. Bedrooms `�~ No. Baths "`, No. in Family _
Garbage Disposal YES ❑ NO
Specifications for _System:
Auto Dish Washer YES NO ❑ �' .`
Auto Wash Machine YES NO ❑ i
Type Water Supply -' `',>; _- �_��%C;it ��t✓l�
t:
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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Improvements permit by
T'— t
*Contact a representative of the Davie County H lth Depaftment for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of comp) tion. Tel phon umber: 704-634-5985.
Final Installation Diagram: S stem Installed by CDPJJA't2, �' T,
V
ti
(9
Certificate of Completion Date J
*The signing of this certificate shall indicate that the system descrabove 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
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.
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Home Phone
1. Permit Requ s ed By O Business Phone sY�" s9y/
2. Address / v �.2 d 7
3. Property Owner if Different than Above
Address 15 6 j LAD-'S C . &_7 1 D
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 Homed Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state sizeof home and number of rooms.
House Dimensions— a j O
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 oC urinals garbage disposal
lavatory a showers washing machine )
dishwashersinks /
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions ZS
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 a best my owledge.
1 8
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
40
411-6or\ CA>
Q'L, IL I r.t-tT NE4c-r -r% �W�
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
PS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) S PS PS PS
U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS PS PS PS
U U U
4) Soil Depth (inches) S S S
/� U 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 S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space 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 ►/ Date
SITE DIAGRAM
DCHD(6-82)