1652 Junction Rd ^••°,xs'.*•,..�'^ ,.y7�uan'+� a.�a�:;.cv.,javF i ,• ..,+w.•..wt•_e:_.r.,saba,arv-n�u..cmn7yv ae.ssv..roq(•a,.•'-..—o.- - .
�_ DAVIE COUNTf� LTH DEPARTMENT
f)16ROVEMENTS PERMIT AND CERTIFICATE: OF COMPLETION,
NOTE:- Issued.in.Compliance with G.S.'of North Carolina Chapter,1,36"Article 13c
Sewage Treat°Ment nd Disposal Rules ,(10 .NCAC••10A .1934-11968), ,Permit Number
�.
Name';�_ t :, II Date. 4644"
i ) ,
Location'
. J,I,d_�i. /,/f J- ; n.. r� / /," �i1'!%�s'lir�� ����,// ;f?' �10/J ,/ Uf•1'/- . . ._ .. - ":•
Subdivision`Name'` Lot No. Sec. or, Block No.
Lot.'Size I: 2 IVK- - .House ti' , Mobile,.Home _ - I. Business Speculation
No. Bedrooms- 'No. Baths No. in Family.��,
Garbage Disposal` YES E NO`� Specif°ications jor System:
Auto Dish Washer YES' NO
Auto-Wash Machine YES, NO ❑ I „ ;
Type Water Supply
-=-:
"This Permit Void.if sewage,system d s ribebelow is not mstalle hin 36 monthsfrom date of issue.
Improvements permit by
r
"Contact a representative of;the Davie, County Health Department for final inspection.of, this system between 8:30-
1. A.M. or. 1:00 1:30.P.M. on day of,completion. TeiLephone Number:'704-634-5,985. ,
j
Final Installation Diagram: System.lnst d by
. ; ..i• .' .( Fes' ,
Certificate of Completion Date (�
.'The signing of this certificate shall indicate that the system described 'above has been installed in compliance with °a
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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. 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
Lp,$' PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, 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
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
PS 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 SpaceS S S
4s,
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 SPS—Provisionally Suitable
Recommendations/Comments:
Described by Title �i� Date
SITE DIAGRAM
/v
DCHD(6-82)
i
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
/ Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone
1. Permit Requested By Lig "� , Business Phone
2. Address
3. Property Owner if Different than Above
Address
4. Permit To: a) Install!!!!::�Alter Repair
b) Privy Conventional-,IZOther Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House 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
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 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. a) Property Dimensions—
b)
imensions b) Land area designated to building site
C) Sewage Disposal Contractor n'0�
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.
X
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
DCHD(6-82)