196 Peoples Creek Rd (2) C,
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 % s Date il 3 1
Location
Subdivision Name Lot No. Sec. or Block No.
Lot Size
House Mobile Home Business ___ Speculation
No. Bedrooms No. Baths No. in Family
Garbage Disposal YES p NO [E] Specifications for System:
Auto Dish Washer YES p NO
Auto Wash Machine YES d NO
7—
Type Water Supply
*This permit Void if sewage system described below is not installed within 36 months from date of issue.
jai J_r
X
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 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.
,
DAVIE COUNTY HEALTH DEPARTMENT
v. Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S
C PSS U PS PS
�� U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) P PS PS
U U U
3) Soil Structure (12-36 in.) S S
Clayey Soils P PS PS
U U U U
4) Soil Depth (inches) -�� S S
PS PS
U '� U U
5) Soil Drainage: Internal S S
jgy> (25-1 PS PS
U U U U
External S S
PS PS PS PS
U U
6) Restrictive Horizons
7) Available Space S S
PS PS PS PS
U U U U
8) Other (Specify) S S S S
PS PS PS PS
U U U
ly
9) Site Classification ,
U—UNSUITABLE S—SUITABLE PS—Provisionally Suitable
Recommendations/Comments:
Described by / Title Date
SITE DIAGRAM
DCHD(6.82)
• RECEIVED APR 14 -1986
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
Home Phone 948-23163
1. Permit Requested�yeJ ,C-A"d CUae/tr- �lUe2s Business Phone g51'ac— 9893
2. Address 7 . X 3 / GWI�_ O A2D
3. Property Owner if Different than Above / U
Address P43 -9 C 3 fidLJAfiP a
4. Permit To: a) Install Alter Repair
b) Privy Conventional_4__I�ther Type
Ground Absorption'
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
Industry Other
b) Number of people '7'
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions /§., X in
i
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 a
lavatory z— showers washing machine Z
dishwasher sinks J
8. a) Type water supply: Public '� Private Community
b) Has the water supply system been approved? Yes No'i
9. a) Property Dimensions Q ilCRet
b) Land area designated to building site
tD U qh l 3
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve? A)CWC,
What type?
This is to certify that the information is correct to the best of my knowledge.
! / ?Lb/&a-.
Date O ner Signatu e
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL STATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
)EINudle niti/lods7' Gtlu2clt fureiv i2tq,0, 90 *, Sec oAd Aocrse o.v
R19k+ R jfjj e, ( gees des, -+urn f/J bRjuecv.4y 90 p455ecl hauSt,_
S-r24i9hF OA d0 w, ) `}-0 WAUS �Nrl e,e j /11� 4.04 /6 ;bdo cel . 1714-11
-- F}fc,k aF `P,Ne+P_ees, ,�e F�Re o 1d b l4Q IJ.
DCHD(6-82)