655 Becktown Rd »z
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' DAVIE COUNTY HEALTH DEPARTMENT </C(j,)/q(�=, /�
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�/. >\°NOTE� |oauad in Compliance with G.S. of North Carolina Chapter 130 Article 13c �
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Sewage Treatment d Disposal Rules (10 NCAC 10A'.1934-.1968) Permit Number
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Subdivision Name Lot No. Soc. or Block No. ` ^
Lot Size House Mobile Home Business -- Speculation
No. Bedrooms No. Baths - No. in Fami|y-_^��---_
Garbage Disposal YES E] NO Er Specifications for System:
Auto Dish Washer YES Ej
/NO El
Auto Wash Machine YESN
Type Water Supply
*This permit Void if sewage system described bo|ovv in not installed within 36 months from date of issue.
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Improvements permit by
*Contact o 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: 704'834'5985.
Final Installation Diagram: System Installed by
/10
Certificate of Completion Date
*The signing of this certificate shall indicate that the system described above has been motaU|oU m oomp|/anoe'with
the standards set forth in the above vogu|a1ion, but shall in NO way be taken an aguanantee that the system will function
satisfactorily for any given period of time.
APPLICATION FOR SITE EVALUATION/IMPROVEM
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
3 pct 5
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 44tr
2 � Home Phone �"_Nmrl
1. Permit Requested By r% �7_ Business Phone
2. Address ; .el
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter . Repair
b) Privy Conventionalt 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
Bed Rooms::�Z 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 Commynity
b) Has the water supply system been approved? Yes No
9. 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 informatiAis, rrect to the best of my n . midge.
X11
Date ' Owner*gr&ural
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. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Date
ss Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
)ography/Landscape Position S S S S
PS PS PS
U U U U
I Texture (12-36 in.) Sandy, S S S
amy, Clayey, (note 2:1 Clay) PS' PS PS PS
U U U
I Structure (12-36 in.) S S S
yey SoilsPS PS PS
'/-�S
U U U
I Depth (inches) S S S S
<'101c ? PS PS PS
U U U U
I Drainage: Internal -S-- S S S
P PS PS PS
C
U U U U
ExternalS S S
X!p� PS PS PS
U U U U
Arictive Horizons
iiable Space S- - 5 .
y SPS PS PS PS
U U _ .0 U
er (Specify) S S S S
PS PS PS PS
,.�U U U. U
Classification
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
mendations/Comments:
ed by /�l/ ;' Title � Date l
I �
AGRAM 1'
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION r
Name Ald Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
cp 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 PS
U U U U
4) Soil Depth (inches) S S S
� ) PS PS PS
L.}f� U U U
5) Soil Drainage: Internal S S S
PS PS PS PS
U U U
External S S S
PS PS PS
U
U U U
6) Restrictive Horizons
7) Available Space 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
9) Site Classification t
U—UNSUITABLE S—SUITABLE �—Provisionally Suitable
Recommendations/Comments:
Described by Title Date-"' X/6
SITE DIAGRAM