124 No Creek Rd 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 ,
i
LocationrA. JLr,
Subdivision Name Lot No. Sec. or Block No.
Lot Size _`L,rl House Mobile Home _ Business Speculation
No. Bedrooms No. Baths No. in Family _
Garbage Disposal YESNO ❑ Specifications for System:
Auto Dish Washer YES [ NO ❑
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.
Improvements permit bye>`=r -f
*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
41-
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 EVALUATION/IMPROVEMENTS PERMIT Iro
Davie County Health Department
Environmental Health Section r v�
P. O. Box 665 i-A-6
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone X351-
1. Permitll��Z 3.�. Business Phone GKN- -2411
Requested By
2. Address -0/ 7./�
70/A.130
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy _ Conventionalx Other Type
Ground Absorption
c) Sub-Divisionec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
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 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 3 showers f washing machine
dishwasher / sinks
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions Z- .�Ats
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? A)o
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:
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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION f
Name //�'� Date - �A
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
U 0 f US
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) PS PS
& U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS P PS
U U U U
4) Soil Depth (inches) S S S
p P PS PS
U
5) Soil Drainage: Internal S S S S
S 11PS
U U U
External S S S
PS PS
U U
6) Restrictive Horizons
7) Available Space r S S
/PS) PS
U
8) Other (Specify) S S S S
PS PS PS PS
U U U U
9) Site Classification
U—UNSUITABLE S—SUITABLE �S—Provisionally S
Recommendations/Comments:
Described by Title Datez4Z&k/
SITE DIAGRAM
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