397 Potts Rd DAVIE COUNTY HEALTH DEPARTMENT
rt 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 ,r i .,,- n\„ t- Date - , . - '. �5�' 9
Location 901 0111- "P—rr4 c � ; a,. . }� .., n 1, I=' r, ;'.�c • -_
Subdivision Name Lot No. Sec. or Block No.
Lot Size o .. House Mobile Home —L-- Business __ Speculation
No. Bedrooms 2__ No. Baths _ I No. in Family__3_.
Garbage Disposal YES ❑ NO D- S Specifications for stem: n _
Auto Dish Washer YES E] NO p y
Auto Wash Machine YES 2- NO ❑ > l
Sf
Type Water Supply �4 ;,t,- 11 _ :�/�.;,, � ��• - ri �� i.frc�,.
'`This permit Void if sewage system described below is not-installed, within 36 months from date of issue.
ILI,
i
j
1
Improvements permit•by
'Contact a representative of thq Davie unty Health Department for final inspection of this system between 8:30-
9:30 A.M. or 1:00-1:30 P.M. o day of ompletion. Telephone Number: 704-634-5985.
Finat,Installation Diagram: System Installed byj� /-tf/fA1(0 40
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
Environmental Health Section
P. O. Box 665
Mocksville, N.C. 27028
/ SOIL/SITE EVALUATION
�/�
Name /?' ARD In'6E Date — 25 -cP3
Address /17° le%J9ei�W% Lot Size ae'?,
"tI--f 2-2,103
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S S S
1�7 PS PS
U U U
2) Soil Texture (12-36 in.) Sandy, S S S
Loamy, Clayey, (note 2:1 Clay) ��p I PS PS
U U U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils -- PS PS PS
U U U
4) Soil Depth (inches) S S S S
1--cm PS PS
U U U
5) Soil Drainage: Internal S S S
(i� PS PS PS
U U U
External ,Cf_ S S
PS PS
U U U U
6) Restrictive Horizons
3
7) Available Space S S S
P 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 PS—Provisionally Suitab
Recommendations/Comments: - a o
Described by
�^� Title ��-- tfs�� �• Date S -ZT-�y
SITE DIAGRA o acQ
2
�4a
DCHD(6-82)
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT
Davie County Health Department
Environmental Health Section I
P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED./
Home Phone � �6
1. Permit Requested By Busin ss Phone
2. Address 7
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
Industry Other
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions X -�
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 V garbage disposal
lavatory ' showers washing machine
dishwasher O sinks / f�
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions �3 o ores
b) Land area designated to building site
c) Sewage Disposal Contractor i C a t4 ( (sb�.
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:
DCHD(6-82)