224 Seaford Rd - DAVIE COUNTY HEALTH DEPARTMENT
IMPROVEMENTS PERMIT AND CERTIFICATE OF -COMPLETION
*NOTE: isjued in Compliance with G.S. of North Carolina Chapter 130 Article 13c }
Sewage Treatment and Disposal Rules (10 NCAC 10A .1934-..1968) ` P@I'1111t Numb@r
'J Name /, . bate �� ,�/' r� " 3263
Location V-V.
Subdivision Name Lot No. Sec. or Block No.
L'ot Size ''>� House Mobile Home _ Business Speculation
No. Bedrooms �1 ; No. Baths _Z No. in Family_
r.
Garbage Disposal YES .0 NO Specifications for S,yste�n
Auto Dish-Washer YES NO ❑ /L r �r :• '"��_ '
Auto Wash Machine a YES NO ❑ ( ,
Type Water Supply
*This permit Void if-sewage system described,below is not installed within;36 months from date of issue.-
•
• - H iii 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;1by A/X- A,
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;
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
1. Permit Requested B Business Phone � 12y
2. Address
3. Property Owner if Different than Above L •Ci G���
Address TN 2L �OX 310' P N 71�1�1�
4. Permit To: a) Install_t,G Alter Repair
b) Privy Conventional Otherk Wpe
Ground Absorption
c) Sub-Division Sec. Lot No.
5. System used to serve what type facility: House Mobile Homer Business
IndustryOther
b) Number of people
6. a) If house or mobile home, state size of home and number of rooms.
House Dimensions VD, is to 5
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,
dishwasher sinks a
8. a) Type water supply: Public Private Community
b) Has the water supply system been approved? Yes-IG No
-"9. a) Property Dimensions 620"A MA-620
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 Si nature
OWNER IS SOLELY RESPONSIBLE FOR COMPLIANCE WITH ALL TATE AND LOCAL LAWS
Allow 5 days for processing
Directions to property:
AewWeeV
DCHD(6-82)
DAVIE COUNTY HEALTH DEPARTMENT
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 S
C PS PS
U U U U
2) Soil Texture (12-36 in.) Sandy, S S S S
Loamy, Clayey, (note 2:1 Clay) 1�) ID U PS
U U
3) Soil Structure (12-36 in.) S S S S
Clayey Soils � � U PS
U
U U
4) Soil Depth (inches) S SS S
PS PS
U U U
5) Soil Drainage: Internal S S S S
PS PS
® U U
External s S S S
S PS PS
U U U
6) Restrictive Horizons
7) Available Space S S S S
PS PS
U IP 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 Suitable
Recommendations/Comments:
Described by Title Date
SITE DIAGRAM
a
DCHD(6-82)