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781 Baltimore Rd Wr ., ;....:.. . ,: ,.. . ,. .� �,. : .. . . .... DAVIE COUNTY HEALTH DEPARTMENT IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION *NO,TE: 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',�' /�✓�/,-.�F Date 4160 Location /._�Sr - i/; �f11J4: Subdivision Name Lot No. Sec. or Block No. Lot Size / House Mobile Home _ Business Speculation No. Bedrooms _�— No. Baths — -� No. in Family — Garbage Disposal YES ❑ NO Specifications for Systerry /., Auto Dish Washer YES 4 NO ❑ /1506 Auto Wash Machine YES [Jj NO ❑ Type Water Supply l `This permit Void if sewage system descritrod 6elo�is-not-in stat led-with i.n 36 months from date of issue. � I 1 1 i' 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 1:00-1:30 P.M. on day of completion. Telephone Number: 704-634-5985. i v Final Installation Diagram: System Installed by ! � ` r Certificate of Completiory<-.� �7 / Date 'The signing of)his c�rtificat"a shall indicate that the system described above as//been installed in compliance with the standards set forth inihe above regulation, but shall in NO way be taken as I guarantee that the system will function satisfactorily for any given ,period of time. i i 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. Home Phone /?S 502/3 1. Permit Requested By _ 41A A Business Phone 99b -83 '3 w,Vie_ 2. Address / vC14WO., C. 3. Property Owner if Different than Above Address 4. Permit To: a) Installer Alter Repair b) Privy Conventional—Lef"Other Type Ground Absorption c) Sub-Division Sec. Lot No. 5. System used to serve what type facility: House_zr_-_Mobile Home Business IndustryOther b) Number of people 3 6. a) If house or mobile home, state size of homeand number of rooms. � House Dimensions rA : y -66 Bed Rooms 3 Bath Rooms !1- 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 '7 urinals garbage disposal lavatory -2- showers .Z washing machine dishwasher sinks / 04©G 8. a) Type water supply: Publics/Private Community b) Has the water supply system been approved? Yes No 9. a) Property Dimensions 6 n c.p 5 b) Land area designated to building site "' c.e-r S 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 the est of my know dge. Date Owner Signature OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS Allow 5 days for processing Directions to property: n ,� J'�aGC mac? 1 ! C/[ e�.a(w�n.ce✓ cc..�.� DCHD(6-82) 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 U U U 2) Soil Texture (12-36 in.) Sandy, S S S Loamy, Clayey, (note 2:1 Clay) P ® PS S U 3) Soil Structure (12-36 in.) S S S Clayey Soils PS PS S PS U U 4) Soil Depth (inches) S S S S PS 5) Soil Drainage: Internal S S S PS PS PS PS External PS U 6) Restrictive Horizons 7) Available Space PS PS Is PS U U U U 8) Other (Specify) S S S S PS PS PS PS Ute- U U U 9) Site Classification U—UNSUIT LE S—SUITABLE La—Provisionally Suitable Recommendations/Comments: Described by TitleDate SITE DIAGRAM I DCHD(6.82) 1