5380 Hwy 601N ' '' '..•�'r.�.a ..,Set,.r. .x'°+:,.,..:':w..� ., ,,.,.. ..,-..s -tea sib;b- t..iii.4,... .h?a rti„�,.: ,. �. `-�..� .•rivs •r�.t� i,....—��r•. - .
DAVIE COUNTY HEALTH DEPARTMENT ey /
: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
Name— 7 Date ,/ /1�J� ?r 2 Q
Location 1 -,�/i(/ /�; ✓ �f .i sr �� .
Subdivision Name Lot No. Sec. or Block No.
Lot' Size _—t-� House Mobile Home _�� Business Speculation
No. Bedrooms — No. Baths No. in Family,__3f —
Garbage Disposal YES ❑ NO ,Ef Specifications for System: /� '
Auto Dish Washer YES NO '❑ i �y;, `� �4�
Auto Wash Machine YES [7]` NO ❑
Type Water Supply
*This permit Void if sewage system described below is not instated w'thin 36 months from date of issue.
�1
Improvements permit by
"Contact a representative of the Davie County HealtVe artment for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completionele hone Number: 704-634-5985.
Final Installation Diagram: ystem Installed by
v
UI
Certificate of Completion ��Z�`''"/ 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.
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name P - Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
PS PS PS
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 PS
U U U
4) Soil Depth (inches) S S S
PS U PS
U
�--� U U U
5) Soil Drainage: Internal S S S
—U PS PS PS
U U U
External S-- 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 U
9) Site Classification ,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described byTitle � /` Date -dT�
SITE DIAGRAM
DCHD(6-82) -
RECEIVED 2 a7 146
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. n
Home PhoneC'Qz 00 79, 02
1. Permit Requested By Q4-�kje 'POC41er, Business Phone
2. Address C
3. Property O.,wner if Different than//Ab`ove 10-0A n -J-),ab tzi__ f
Address #'5 j>' y`�'9 mtgc-7 'w /� -e1 l� C, X70
4. Permit To: a) Installfe"'Alter Repair
_by-Privy---Oonvientional _Other Type
,Grourni-Absorption
c�Sub Aivisinn ��------ Lit-P!o
5. System used to serve what type facility: House Mobile Homed Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of ho a and number of rooms.
House Dimensions X LI 11 D--5c/
Bed Rooms Bath Rooms Den w/Closet
Gther-State�er-ef-persons-served
Mftkj type business etc.
ttt-e#-waste-d ai+ ea�
7. Number and type of water-using fixtures:
commodes a urinals garbage disposal
lavatory- __2 showerswashing machine
dishwasher sinks
8. a) Type water supply: Public Private_I Community
b) Has the water supply system been approved? Yeses No
9. a) Property Dimensions ��� �'� f-�� �'- �lL�
NJ
b) Land area designated to building site
c) Sewage Disposal Contractor W R • S cJ r-n-)n r") .S n tit S
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
AXq
11 This is to certify that
that the information is correct 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:
0-/Yv1J� 1
DCHD(6-62) '