1572 Junction Rd t�
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
Name Date
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size '%'(' House Mobile Home _L' Business Speculation
No. Bedrooms �f No. Baths No. in Family Z _
Garbage Disposal YES ❑ NO p Specifications for:. System; - A ,
Auto Dish Washer YES ❑ NO p' ,
Auto Wash Machine YES Er'NO -E] /G6-G
Type Water Supply �/',-1
"This permit Void if sewage system described below is not installed within 36 months from date of issue.
4
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Improvements permit by
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"Contact a representative of the Davie County Health Department for findl inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day of completion. Telephone Number: 704634-5985.
Final Installation Diagram: System Install d b
�
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.
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' DAVtt�GOJNTY HEALTH DEPARTMENT
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name � r�- Date
Address Lot Size�° �'�
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
PSS PS PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, _'_� S S
Loamy, Clayey, (note 2:1 Clay) PSP ' PS PS
U U U
3) Soil Structure (12-36 in.) � S S S
Clayey Soils (P N PS PS PS
U U
4) Soil Depth (inches) S S
PS PS PS PS
U U
5) Soil Drainage: Internal �..�,, S S
S j(P5J PS PS
U U
External S S S
PS PS PS
U U
6) Restrictive Horizons
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7) Available Spaceis
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 —FIT W57-1
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by Title Date .Ll�
SITE DIAGRAM
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DCHD(6-82) i
PLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMITy9.
Davie County Health Department ` ^
Environmental Health Section a
R O. Box 665 s
Mocksville, N.C. 27028
y
CO) ACTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone -��/✓
1. Permit Request d By 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 Mobile Home Business
IndustryOther
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
dishwasher sinks /
8. a) Type water supply: Public PrivateyCommunity
b) Has the water supply system been approved? Yes y No
9. a) Property Dimensions !: '
b) Land area designated to building site �-
c) Sewage Disposal Contractor r I I
10. Do you anticipate any additions or expansions o(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 nowledge.
Date Own r 9.9nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AN LOCAL LAWS
Allow 5 days for processing
Directions to property:
AI
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A-' yy ac c r 65 S o v�
C )'v\e"h C a 61 1 b
DCHD(6-82)