211 Salmons Rd .. - - a+c..,:y+c:.r.o:.._r--w:-.rai....�w...r....,-•: -:i:..... ...a.......f:�_:.Y'�i 4..,-.L 4 '-'�.a+�.:.. Y:w v' `°. �_ .w»�. .+... �-« u v .. ... .._
'. 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 fk ;� �' l � ..�1�'.,J Date ���%. / r(� �►= -14 3
Location '%�if,J !� •�-L�''f /��,.ttr�- `/ ' s ✓ J /r� ��r_d
*�
Subdivision Name----------- Lot No. Sec. or Block No.
ZA
Lot Size '/- (i/ WH use ��J Mobile Home Business Speculation
No. Bedrooms �:! _.No. Baths ' No. in Family
Garbage Disposal -- --YES ❑ NO ❑ _-\� Specifications for System:,
Auto Dish Washer YES NO ��c ,.%
Auto Wash Machine YES NO ❑
145 � ,
r
Type Water Supp Y
*This permit Void, f_sewage,system described below is not installed within 36 months from date of issue.
- i
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 by
E
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 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
f > SOIL/SITE EVALUATION /
Name �� P�i1✓ Date
Address Lot Size
FACTORS AREA 1 AREA 2 AREA 3 AREA 4
1) Topography/Landscape Position S S
C PS PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S
Loamy, Clayey, (note 2:1 Clay) PS PS PS
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
- PS PS PS
U U U
5) Soil Drainage: Internal S S
p (PS J PS PS
U U
External S S
S PS PS PS
U 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 U
9) Site Classification -
U—UNSUITABLE S—SUITABLE —Provisionali Suitable
Recommendations/Comments:
Described by Title. Date
SITE DIAGRAM
DCHD(6-82)
RECEIE/� L 14 190
APPLICATION FOR SITE EVALUATION/IMPROVEMENTS PERMIT OS
Davie County Health Department
Environmental Health Section
U P. 0. Box 665
Mocksville, N.C. 27028
CONSTRUCTION SHALL NOT BEGIN UNTIL IMPROVEMENTS PERMIT HAS BEEN ISSUED. 04 ` 7 tC
�
�_
Home Phone 9 -7ted By nn1. Permit Reques -o
Business Phone qV. 5561 5
2. Address 0 (^ f'3 is'7 - 4tobC,
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: HouseV Mobile Home Business
Industry Other—
b)
ther b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions
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
lavatory showers washing machine l
dishwasher — sinks 1
8. a) Type water supply: Public Private V" Community
b) Has the water supply system been approved? Yes No
9. a) Property Dimensions 26- � Oe'Kl
b) Land area designated to building site 1 l'iCne,
c) Sewage Disposal Contractor
10. Do you anticipate any additions or expansions of the facility this sewage system is intended to serve?
What type? ,�ti(n�G-C Q `�/��rn ��-L� - �i°�n-t c�r �� � /56
10 �—
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:
cup
DCHD(6-82)