800 Redland Rd DAVIE COUNTY HEALTH DEPARTMENT
- q , IMPROVEMENTS PERMIT AND CERTIFICATE OF COMPLETION
*NOTE: Issued in Compliance-with-G.S. of North Carolina Cnpter 130 .Article ..13c
Sewa e Treatment and Disposal Rules (10 NCAC 10A .1934-.1968) Permit Number
Name .- y 3819
Date
Location % , / i� �'_C
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 ❑ NO Ej 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.
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Improvements permit by
'Contact a representative of the Davie County Healthr'bepartment 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
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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.
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APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT ' 2
Davie County Health Department .
Environmental Health Section
R O. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED.
_ Home Phone 72 S 190
1. Permit Requested By eA Business Phone -7451 G 2U
2. Address -AtS 6eckr- t vS _XQ6C4I�IJ n:g 'Sal .w� hSG_ 2_
3. Property Owner if Different than Above
Address 60�:_ 2,a5 tl0'-,'c-C Me- 2--704c,
4. Permit To: a) Install-ZAlter Repair
b) Privy ConventionaliZOther Type
Ground Abs r tion
c) Sub-Division NIA Sec. Lot No.
5. System used to serve what type facility: House Mobile Home Business
IndustryOther
b) Number of people I
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions 27 wt 32 1 I1L SA"6r'�j
Bed Rooms' Bath Rooms 2 Den w/Closet �d
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 2 urinalsy garbage disposal
lavatory. Z- showers 2 washing machine
dishwasher sinks
8. a) Type water supply: Public__Private Community
b) Has the water supply system been approved? Yes NoJeLf
9. a) Property Dimensions I Q S V- 35 10 ' 105 °S 3 5 3
b) Land area designated to building site 3704 S
c) Sewage Disposal Contractor C C0tks Y`0 Ga".^v'%JCA
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.
2- - 2-2- - 8S G t sl�Q�
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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DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
Environmental Health Section
R 0. Box 665
Mocksville, N.C. 27028
SOIL/SITE EVALUATION
Name /E%S �LDate
Address Lot Size
FACTORS. AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position C"—}'-,, � PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) S PS PS PS
U U
3) Soil Structure (12-36 in.) S S
Clayey Soils PS PS
U U - U U
4) Soil Depth (inches) S S
PS PS
�T U U
5) Soil Drainage: Internal S S
PS (P5) PS PS
b� U U
External S S S S
PS PS PS PS
U U U U
6) Restrictive Horizons
7) Available Space S S S
PS PS
U 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—Provisional{y Suitable____Recommendations/Comments:
Described by - - Title ��� Date
SITE DIAGRAM
DCHD(6-82)