2421 Hwy 801N kms,,
DAVIE COUNTY HEALTH DEPARTMENT l rj
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-.1''968) Permit Number
Name rfJ
Location ` x ,
F Y
Subdivision Name Lot No. Sec. or Block No.
Lot Size( House -"` Mobile Home _ Business Speculation
No. Bedrooms %J No. Baths = No. in Family _
Garbage Disposal YES p NO p--'
Specifications for System:
Auto Dish Washer YES NO
f/h
Auto Wash Machine YES NO _
Type Water Supply
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
I
Improvements permit by _—
*Contact a representative of thevie\ounty Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M.``on aK o� C\'< ion ele hone Number: 704-634-5985.
Final Installation Diagram: �� System Installed by r �1
l ,
Certificate of Completion t�. . 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.
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT fUlt`'
Davie County Health Department
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
1�
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEf4 IS�D/ �T
_ Home Phone
1. Permit Requested B - 7 Business Phone
2. Address
3. Property Owner if Different than Above
Address
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 z/ Mobile Home Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 3 Z-
Bed Rooms Bath Rooms Z 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. 2' showers washing machine
dishwasher sinks L�
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions l 4 LAGS
b) Land area designated to building site C�G
c) Sewage Disposal Contractor V S hailLLi
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? >t) y
What type? �—
This is to certify that the information is correct to the best of my knowledge.
-iz' - � -
Date Owner Signature
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)
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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
C �� PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) � � � PS
U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils PS s P PS
U
4) Soil Depth (inches) S S S S
PS PS PS
c::nrr> U
5) Soil Drainage: Internal S S S S
PS PS PS PS
U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S
PS 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 P,S—Provisionally Suitable
Recommendations/Comments:
Described by Title �: Date
SITE DIAGRAM
DCHD(6-82