6725 Hwy 801S DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION 4 =
*NOTE: Issued in Compliance with G.S. of North Carolina Chapter 130 Article 13c i
.� Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) �.- Permit Number
Name r r !' ill:✓ Date _.� pi 3977
Location3r.�
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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 Er' ,.
Specifications for..System.
Auto Dish4vasher YES NO ❑ !'
Auto Wash Machine YES NO -❑ .� A
/ ✓ C
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from:date of issue.
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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.
Final Installation Diagram: System Installed by r
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FL
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Certificate of Completion
P
y
*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.
2
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT V,
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.
Home Phone z84 2397
1. Permit Requested By RO.FSEST A-, XR06D6V Business Phone 9�9 X79-5�7
2. Address 236K. 9�5 ,� C'�OG��"/VIEE , IV.r. 2_76/
3. Property Owner if Different than Above 5AM
Address
4. Permit To: a) Install Atter Repair
b) Privy Conventional Other Type
Ground Absorption
c) Sub-Division Sec. _Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of ho a and number of rooms.
T
House Dimensions ,7Q x
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 3 urinals D garbage disposal
lavatory 3 showers washing machine
dishwasher sinks
8. a) Type water supply: Public V1 Private Community
b) Has the water supply system been approved? Yes No2l,
9. a) Property Dimensions L 32 - ' ff s
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 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:
Fro 6)q,5yq5y co)qNe� y� � GEST -�whRDs
Sol 5 0 qT � M I L e 7NO /11 cS���Fsy caR N3E5 /DE
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PREAC -EA 7-466LE'5 fib qs15_,
DCHD(6-62)
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
PS PS
_ U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) 1'S�` PS PS
U U
3) Soil Structure (12-36 in.) S S S
Clayey SoilsC�p PS PS PS
U U
4) Soil Depth (inches) S S S S
PS PS
U U
5) Soil Drainage: Internal S S S
S" PS PS
U U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space -5 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
C. C-_.
Recommendations/Comments:
Described by �i �/ Title Date1e
SITE DIAGRAM
lJ
DCHD(6-82)