550 Gladstone Rd ~` DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
' *NOTE: Issued in Compliance with G.S. of North Carolina Chapterl>3h Article 13c
Sewage Treatment and,Disposal Rules (10�N 69-R934-.1968) Permit Number
Name ! }> ��/ !% �' �S'! f � ,� Date
Location ,' %;
Ono
Subdivision Name Lot No. Sec. or Block No.
Lot Size .!' Y'":?!`!) House Mobile Home / Business Speculation
No. Bedrooms — No. Baths _ No. in Family 2
Garbage Disposal YES ❑ NO ❑,- Specifications for System:
Auto Dish Washer YES NO ❑ , >;,� fs Y
Auto Wash Machine YES NO ❑ i
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
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
I
I
Certificate of Completion ����� 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 ION/IMPROVEMENTS PERMIT
Davie County Health Department �r
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
ome Phone ! —
1. Permit Requested y V , &,,,H
Cusiness Phone
2. Address '1CXI
3. Property Owrler if iff ent than Above r
Address P' e IV
4. Permit To: a) Install ' Alt Repair er Y)10t"C-. i •� R� '1�&Z_ f�n1
b) Privy t�Conventional Other Type—
Ground
ype Ground Absorption
c) Sub-Division Sec. Lot No. //Aj
5. System used to serve what type facility: House Mobile Homed Business
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and kumber of rooms. C�
House Dimensions I a8
Bed Rooms Bath Room en 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�l urinals garbage disposal
lavatory showers washing machine �4
dishwasher sinks
8. a) Type water supply: Public Private' Com nity
b) Has the water supply system been�_ japproved? Yes No
9. a) Property Dimensions f ]t
b) Land area designated to building site V<S
c) Sewage Disposal Contractor a '�
10. Do you anticipate any additions or expan ions 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:
i � :�, -tii"- .,/
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N IL
DCHD(6-62)
' 1
• DAVIE COUNTY HES TH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date yl���
Address Lot Size lie
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position �., S pS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) Z* PS PS
U U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils �/P� � PS PS
---��j U U
4) Soil Depth (inches) S S S
PS PS
U U U U
5) Soil Drainage: Internal ,�S�.� S S
�b Lj� PS PS
U U U U
External S S S
(k) I - PS PS
U U U
6) Restrictive Horizons
7) Available SpacePS
S S
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 4
U—UNSUITABLE S—SUITABLE, el"PS—Provisionally Suitable
Recommendations/Comments:
Described by , ' -�!1� Title Date
SITE DIAGRAM
DCHD(6.82)