152 Paw Paw Ln (2) .-
D
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
,c"ry 8� �'�-,�
Name �, „ C fJ7ri�.J/Cfit/.lg Date t� No 5296
Location 45,2a/r— — ..lr� r.. - � ���,� -5—��J02�
Subdivision Name Lot No. Sec. or Block No.
Lot Size le!��%ey House Mobile Home'" Business Speculation
l/
No. Bedrooms — No. Baths No. in Family _
Garbage Disposal YES .C] NO (a Specifications for System:
Auto Dish Washer YES NO p
Auto Wash Machine YES [�j NO p
Type Water Supply
*This permit Void if sewage system described below is of installed within 36 months from date of issue'.
Improvements permit by
.*Contact a representative of the 8 my Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. on day o mpletion. Telephone Number: 704-634-5985.
Final Installation Diagram: System Installed by a �
lc� 0i / 6 �f S -'a wQ
M �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 EVALUATION/IMPROVEMENTS PERMIT R9,
Davie County Health Department
Environmental Health Section "
P. O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 4�41�_
1. Permit Requested By Business Phone
2. Address S — pC sv
3. Property Owner if Different than Above
Address
4. Permit To: a) Install Alter Repair
b) Privy Conventiona4zother Type
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home_j'_business
rC/ Industry Other
b) Number of people
6. a7 If house or mobile home, state size of home and number of rooms.
House Dimensions JV
Bed Rooms ` Bath Rooms 1 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 Private_ Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 1-19
b) Land area designated to building�kiw2z/
c) Sewage Disposal Contractor Z2_af
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:
r
C loss ®rn ' 'q '/
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section.
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size--
FACTORS
ize FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
(p,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
U U U
3) Soil Structure (12-36 in.) S S S
Clayey Soils PS PS PS
U U U
4) Soil Depth (inches) S S S
PS PS PS
U U U
5) Soil Drainage: Internal S S S
PS PS PS
U U U
External S S S
PS PS PS
U U U
6) Restrictive Horizons
7) Available Space A) S S 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 c
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by ��� Title Date
SITE DIAGRAM
DCHD(6-82)