327 Four Corners 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
/.' 1�< �/Y- JI
Name 1. .� ,c�f G1 / o° 1 G Date
Location
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 [�� Specifica ions for System r?
Auto Dish Washer YES NO ❑ /�G) %;
LU
Auto Wash Machine YES NO ❑ / �, j�,rj
Type Water Supply
*This,permit Void if sewage system described below is n t '�tatted within 36 months from date of issue.
Improvements permit by
*Contact a representative of the Davie County Health De artment f r final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Tel ph ne Umber: 704-634-5985.
Final Installation Diagram: S stem I stalled by - � � l
G`
Certificate of Completion �i ��' Date
*The signing of this certificate shall indicate that the 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 function
satisfactorily for any given period of time.
S
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 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 S
PS PS PS
U' U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) /pS} 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
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
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date �v
SITE DIAGRAM
U
DCHD(6.82)
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�
1. Permit Req ste�,By
Business Phone
2. AddressR� �'��d�
3. Property Owner if Different than Above
Address
4. Permit To: a) Install �er Repair
b) Privy Co nventionaIZZ 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 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
dishwashersinks
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
10. Do you anticipate any additions or expansio of the facility this sewage system is intended to serve?
What type?
This is to certify that the informationY'c
rrect to the best of my knowledge.
Date Owner Signature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
1�
DCHD(6-82)