172 Jesse King Rd a, fi
00
y,.•.�; ' 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 rAJ
G•-y- /2 i
Subdivision Name Lot No. Sec. or Block No.
Lot Size House Mobile Home Business Speculation
No. Bedrooms 2- No. Baths 2-- No. in Family
Garbage Disposal YES ❑ NO ❑
Specifications for System:
Auto Dish Washer YES ❑ NO E] p " ' Yt ���
Auto Wash Machine YES E] NO
❑ � "� SI�r✓�
Type Water Supply ems' cr? t'��,..• nz r Q-t:
`This permit Void if sewage syst4 described below is not installed within 36 months from date of issue.
.Improvements permit by 1/
*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 �Si
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Certificate of Completion �r (� 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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DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028`
SOIL/SITE EVALtlATION
h �07�GE
Name � Date -7
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position Sr S S S
(i / PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) ® 42!5 PS
U . U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils CD C15tllj' PS
U U U U
4) Soil Depth (inches) S- S S S
<2D PS
U U U U
5) Soil Drainage: Internal S
PS PS PS PS
U U U U
External cS _ a S
PS PS -PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S. S S
PS �_..... PS
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 S—Provisionally Suitable
Recommendations/Comments:
Described by Title 'sem' '` Date 7—
SITE DIAGRAM
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DCHD(6-82)
10(r
APPLICATION FOR SITE EVALUATION/IMPROVEMENT
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 IT Z
1. Permit Requested 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.
System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people 3
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
Bed Rooms Z' 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 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
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 Sidhature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
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DCHD(6-82)